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Transcript of © Copyright, The Joint Commission Advanced Certification in Heart Failure Measures Pilot Test...
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Advanced Certification in Heart Failure Measures
Pilot Test Training
Part II: Tuesday, November 15, 2011
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ACHF-04a Hospital Outpatient Assessment of Functional Status for Heart Failure
Denominator: All heart failure patients
Numerator: Patients for whom a NYHA Class OR completion of a valid, reliable disease-specific instrument was documented at the time of the initial outpatient visit.
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ACHF-04a Included Populations
E/M Code for hospital outpatient encounter as defined in OP Appendix A, OP Table 1.0, and
An ICD-9-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1
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ACHF-04a Data ElementsDenominator: BirthdateDischarge StatusE/M Code ICD-9-CM Other Procedure Codes ICD-9-CM Principal Diagnosis Code ICD-9-CM Principal Procedure CodeOutpatient Encounter Date
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ACHF-04a Data ElementsNumerator:
Disease-Specific Instrument
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ACHF-05a Hospital Outpatient ICD Counseling for LVSD
Denominator: Heart failure patients (NYHA Class II and III) AND documentation of a current LVEF < 35%, despite optimal medication (ACEI/ARB/BB) management for at least 3 months
Numerator: Patients who receive ICD counseling when seen in the outpatient setting and have documentation of the discussion with a healthcare provider present in the medical record
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ACHF-05a Included PopulationsE/M Code for hospital outpatient encounter
as defined in OP Appendix A, OP Table 1.0, and
An ICD-9-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1
Documentation of LVSD < 35%Documentation of Optimal Medication
Management for at Least 3 MonthsNYHA Class II / III
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ACHF-05a Excluded PopulationsPatients with NYHA Class I or IV heart
failurePatients with a documented Reason for
No ICD Counseling in the Outpatient Setting
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ACHF-05a Data ElementsDenominator: BirthdateClinical TrialDischarge StatusE/M Code ICD-9-CM Other Procedure Codes ICD-9-CM Principal Diagnosis Code ICD-9-CM Principal Procedure Code LVSD < 35%
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ACHF-05a Data ElementsDenominator: Optimal Medical Management For at least 3
MonthsOutpatient Encounter DateReason for No ICD Counseling in the Outpatient
Setting
Numerator: ICD Counseling
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ACHF-05b Hospital Outpatient Cardiac Resynchronization Therapy (CRT, CRT with pacing CRT-P, CRT with defibrillator CRT-D)
Denominator: Heart failure patients (NYHA Class II, III, or IV) with most recent LVSD < 35%, QRS duration on ECG of 150 ms or above, left bundle branch block (LBBB), and receiving optimal medication management for at least 3 months
Numerator: Patients who have cardiac resynchronization therapy (CRT) when seen in the outpatient setting
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ACHF-05b Included Populations
E/M Code for hospital outpatient encounter as defined in OP Appendix A, OP Table 1.0, and
An ICD-9-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1
Documentation on ECG of Left Bundle Branch Block (LBBB) and QRS duration of 150 ms
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ACHF-05b Included Populations
Documentation of LVEF < 35%Documentation of New York Heart
Association Classification II, III, or IVDocumentation of Optimal Medication
Management for at Least 3 MonthsDocumentation on ECG of QRS
duration of 150 ms or above
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ACHF-05b Excluded PopulationsPatients with NYHA Class I heart
failurePatients with a documented Reason for
No Cardiac Resynchronization Therapy (CRT)
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ACHF-05b Data ElementsDenominator: BirthdateDischarge StatusE/M Code ICD-9-CM Other Procedure Codes ICD-9-CM Principal Diagnosis Code ICD-9-CM Principal Procedure Code LVEF < 35%Optimal Medical Management For at least 3
Months
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ACHF-05b Data ElementsDenominator: Outpatient Encounter DateReason for No Cardiac Resynchronization
Therapy (CRT) in the Outpatient Setting
Numerator:Cardiac Resynchronization Therapy (CRT)
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ACHF-06a Hospital Outpatient Activity Recommendations
Denominator: All heart failure patients
Numerator: Outpatients who have received a document describing individualized activity recommendations tailored to their needs. This document must be present in the outpatient record
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ACHF-06a Included Populations
E/M Code for hospital outpatient encounter as defined in OP Appendix A, OP Table 1.0, and
An ICD-9-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1
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ACHF-06a Excluded PopulationsPatients with a documented Reason for
No Activity Recommendations
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ACHF-06a Data ElementsDenominator: BirthdateDischarge StatusE/M Code ICD-9-CM Other Procedure Codes ICD-9-CM Principal Diagnosis Code ICD-9-CM Principal Procedure CodeOutpatient Encounter DateReason for No Activity Recommendations
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ACHF-06a Data ElementsNumerator:
Activity Recommendations Document
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Navigating the Advanced Certification
Heart Failure ProjectData Collection Tool
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GET STARTED
Access the project website at: http://manual.jointcommission.org
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ACHF PROJECT PAGE
From this page you can:• Access your hospital page• Access the Measure and Data Element info• Find data submission dates• Submit questions and provide feedback• Find news, tools and other resources that may become available during the project
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YOUR HOSPITAL PAGE
From this page you can: Add or update your hospital information Enter new records View and update existing records Mark records as “complete” Review records that have been completed Identify records that have been flagged for re-abstraction
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View and update existing records
Click the Pencil icon to “Edit” an existing record
Click the UBCI number to “expand” an existing record
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Mark records as complete
Click the empty box to “Complete” and
“Lock” a record
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Review records that have been completed
Click the “Complete” radio button and then click “Filter”
to view completed records
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Identify records flagged for re-abstraction
The “Lock” icon means the record is complete. The blue
flag icon means the record will be re-abstracted.
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ENTERING NEW RECORDSNote: hovering over the green ‘i’ next to a data element will show you the question and allowable values associated with that data element.
Clicking on the green ‘i’ will link to the data element page.
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ENTERING NEW RECORDS
Once you have completed data entry for this record, save the data record.
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DATA ENTRY CASE SCENARIOS general patient data elements
Blue arrows show elements used by
Inpatient and Green arrows
Outpatient.
Red arrows show elements used by both Inpatient and
Outpatient.
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general patient data elements
Red arrows show elements used by both Inpatient and
Outpatient.
Blue arrows show elements used by
Inpatient and Green arrows Outpatient.
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INPATIENT SECTION
All elements from ‘Bisoprolol’ down to ‘Post-Discharge’ are
Inpatient only. If Inpatient record, please fill in ALL elements.
If an Outpatient record – you can leave all Inpatient
elements blank
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OUTPATIENT SECTIONAll elements from ‘Bisoprolol in Outpatient
Setting’ down to ‘Reason No Activity’ are Outpatient only. If Outpatient record,
please fill in ALL elements.
If an Inpatient record – you can leave all Inpatient
elements blank
Click “Save Data Record” when all data entry is finished for the patient
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FIND EXISTING RECORDS
To find a record by Unique Blinded Case Identifier (UBCI), enter the UBCI and ignore the “Complete” and “Incomplete”,
then click “Filter” button.
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VIEW RECORD’S DETAILSTo view an existing record, click on the UBCI number. You can contract the drop down
by clicking on the ‘-’or expand by clicking on the ‘+’ before the different sections.
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EDIT EXISTING RECORDS
To edit the “General and other patient-level data elements”, click on the pencil icon.
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VIEW EXISTING RECORDS
To view the complete records, check the “Complete” radio button then click “Filter” button.
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REVIEWING COMPLETED RECORDS
The completed records are LOCKED and can not be edited. The blue flag indicates that record will be re-abstracted.
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UNLOCK A RECORD
To send an e-mail request to unlock a record, click on the “lock” icon and an e-mail form will appear. In the e-mail, please briefly explain why the record needs to be
unlocked (e.g., Accidentally clicked the “Complete” checkbox).
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ASK A QUESTION
On the ACHF project page – the very bottom
has a link to ask a clinical or technical
question. The FAQ table also will display the common questions.