michigan care improvement registry: data quality principles & best practice strategies ·...

MICHIGANCAREIMPROVEMENTREGISTRY:DataQualityPrinciples&BestPracticeStrategiesMichiganDepartmentofHealthandHumanServices.MCIROngoingDataQualityImprovementPlan(ver.August31,2015):Section3,DataQualityPrinciples.

MICHIGANCAREIMPROVEMENTREGISTRY:DataQualityPrinciples&BestPracticeStrategiesJune3,2016/Page1of21

DATA QUALITY PRINCIPLE #1

CONSISTENCY The conditions (criteria) for validating data items should be the same regardless of how the data items have been reported into the correct MCIR record.

Example(s): ü Regardless of a data item’s source and the method of data reporting (e.g., direct user

entry, EXT, or HL7 reporting), the data item should go through the same set of data validation checks (conditions/criteria).

Provider Best Practice (BP): The provider is responsible for monitoring patient demographics or other identifiers to ensure an exact match of data reported into the MCIR record.

Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider Best Practice. • EXT and HL7 Information at www.mcir.org • MCIR DQI Business Plan Perform required regional MCIR data analysis or correction, as necessary. Make appropriate referrals, when necessary.

MCIR Resource Materials:

Visit www.mcir.org for appropriate tip sheets and related resources


DATA QUALITY

PRINCIPLE #2

REJECTED DATA

When information is not accepted it still can be held (in some buffer zone) for a further research or rejected outright. When information is rejected by MCIR, the following actions should occur:

• Electronic import logs errors and notifies submitters • HL7 users can generate an Electronic Submission Summary Report (ESSR) • User Interface (UI) displays an error message, offering user opportunity for error

correction Example(s):

ü MCIR Electronic Submission Summary Report (for HL7 users) ü Summary and VIM Transaction Report (for EXT users) ü Doses Administered Report, along with available inventory reports, assist the end

user in finding, correcting and resubmitting data errors. ü UI users receive edit checks verifying information on the screen, before data

submission. Provider Best Practice (BP): The provider should perform quality assurance tests daily and report data issues.

Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider




Best Practice. • EXT and HL7 Information at www.mcir.org • MCIR DQI Business Plan

Perform required regional MCIR data analysis or correction, as necessary. Make appropriate referrals, when necessary.


DATA QUALITY

PRINCIPLE #3

INTERNAL CONSISTENCY

Characteristics of the vaccination history should not contradict one another. This includes reported data as well as existing MCIR data. (This principle is a basis for all crosscheck validations. This principle covers cross-validations between characteristics of multiple vaccination events that comprise immunization history, as well as cross-validations between characteristics of individual vaccination events. Vaccination history includes demographics, and information on all recorded vaccination events.)

Example(s):

ü Vaccine type should match administration route. Also, vaccine type should be paired with the licensed vaccine manufacturer.

Provider Best Practice (BP):

The provider should report potential data quality issues to MCIR Regional staff for verification.

Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider Best Practice. • #02-04 MDHHS MCIR Policy for Person and

Vaccine Deduplication • #02-05 MDHHS MCIR policy for Record




Corrections • #06-01 MDHHS MCIR Policy for Site/User

Training and MCIR Training Checklist




ACCURACY The data recorded in MCIR should match exactly what happens in a clinical encounter, whether or not it is clinically appropriate.

Example(s): ü Recommended for MCIR staff to periodically audit a random sample of incoming data

to verify that it matches clinical records. ü Submitters should periodically audit a random sample of data to verify that it is

correctly documented in MCIR. Provider Best Practice (BP): The provider office administering immunizations shall accurately document doses given under their MCIR site ID

Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider Best Practice. • MCIR DQI Business Plan






The provider site should maintain a MCIR vaccine inventory for the purpose of accountability and accurate documentation of administration.

Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide for appropriate Regional MCIR procedures, as it relates to the Provider Best Practice. • #06-01 MDHHS MCIR Policy for Site/User






Use exact antigen/vaccine information when documenting administered or historical immunizations when available (e.g., Hib PRP-OMP; Unspecified vaccine types like Hib or NOS are less desirable)

Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider Best Practice. • #02-04 MDHHS MCIR Policy for Person and




vaccine Deduplication • #02-05 MDHHS MCIR policy for Record

Corrections • MCIR DQI Business Plan



The provider site should periodically audit MCIR data to ensure an accurate match data recorded in the EHR and/or clinical record(s)

Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider Best Practice.





DATA QUALITY

PRINCIPLE #5

APPROPRIATE VACCINATION

The vaccinations reported by a provider should be appropriate for the population served at the clinic.

Example(s): ü In a pediatric practice, certain types of vaccines are used in a certain proportion, e.g.,

a certain percentage of DTaP, polio, Hib, and MMR is to be expected.


The provider should integrate a process(es) into the medical practices’ workflow which requires the review of MCIR data, and the required cross-referencing with EHR/medical record data, prior to determining immunizations to be administered during an office visit.

Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider Best Practice. • #06-01 MDHHS MCIR Policy for Site/User







The provider office should routinely generate Profile Reports and Dose Administered Reports (DAR) to monitor office immunization assessment levels and ensure individuals seen within the clinic are up-to-date on required vaccinations.


Training and MCIR Training Checklists





DATA QUALITY

PRINCIPLE #6

VITAL RECORDS

Vital Records is the definitive source for the following MCIR data fields:

• Date of Birth • Date of Death • Adoption • Validation of correct demographic information • Management of duplicate EBC records

Example(s): ü It is possible that an incorrect birth date or death date is transmitted from vital records,

but those are rare occasions. ü End users may flag a person as deceased. ü A feed from vital records also provides an electronic file of official death records to

MCIR. ü Adoption records are managed at the regional level.


The provider should use the applicable demographics and unique identifiers when searching for the individual’s MCIR record, to ensure an exact record match.

Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider Best Practice. • #01-05 MDHHS MCIR Policy for Processing




Name Changes and Merges Due to Adoption • #02-03 MDHHS MCIR Policy for Person

Searches • #02-05 MDHHS MCIR Policy for Record

Corrections



The provider should review, and make the required updates, to an individual’s demographics and Patient Status whenever contact is made with patient information

Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider Best Practice. • #01-05 MDHHS MCIR Policy for Processing

Name Changes and Merges Due to Adoption • #02-05 MDHHS MCIR Policy for Record

Corrections • #02-06 MDHHS MCIR Policy for Patient

Status & Person Does Not Receive Medical Care in Michigan





VALIDATION PRIORITY The importance of validating a data item is related to the data item’s significance in clinical decision-making, public health assessments, and research.

Example(s): ü Critical high priority data items are:

o Vaccine Type o Vaccination Encounter Date o Eligibility o Lot number o Manufacturer o Date of Birth • Zip Codes


The antigen/vaccine information entered by the provider should match exactly the information on the vaccine manufacturer’s box/insert and the MCIR inventory, if/when applicable.



Perform required regional MCIR data analysis or




correction, as necessary. Make appropriate referrals, when necessary.


DATA QUALITY

PRINCIPLE #8

ACIP RECOMMENDATIONS PRINCIPLE

Deviations from ACIP recommendations and U.S. licensure may indicate data quality problems.

Example(s):

ü MCIR does not accept immunization data prior to person DOB. ü If a date of birth is modified on a MCIR record, it could result in some vaccine

encounter dates being documented before the date of birth. ü Immunization assessment issues


The provider should routinely run recall to identify and notify patients whose MCIR record indicates they are overdue for immunizations








The provider should routinely utilize MCIR assessment (i.e., vaccination forecasting tool, status screen, batch report, printed record) when assessing an individual for required and recommended vaccine administrations.







DATA QUALITY

PRINCIPLE #9

TIMELINESS

Michigan Department of Health and Human Services requires immunization data to be entered into MCIR within 72 hours of administration for children less than 20 years of age.

Example(s):

ü To be useful for clinical decision support and health policymaking, immunization data should appear in the MCIR soon after the clinical event occurs.


The provider office should standardize an office practice by which immunizations are recorded into the EHR (or onto a clinical chart) and added to the MCIR timely – within 72 hours (3 business days of administration). Refer to DQ Principle #10.

Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider Best Practice. • #02-01 MDHHS MCIR Policy for Provider

Reporting Compliance • MCIR DQI Business Plan






COMPLETENESS The information submitted to MCIR must contain the minimum/mandatory set of data items in order to be accepted by MCIR.

Example(s): ü Required data fields and the minimum/mandatory data sets for necessary MCIR

function and operation ü Relevant data is optional and of value in improving MCIR function. The goal is to

capture all relevant data on persons and their vaccination events. Provider Best Practice (BP): The providers generate, review and correct errors found on EXT submissions and HL7 Electronic Submission Summary Reports (ESSR) daily, at minimum every 72-hours.


Training and MCIR Training Checklist • MCIR DQI Business Plan Perform required regional MCIR data analysis or correction, as necessary.




Make appropriate referrals, when necessary. Provider Best Practice (BP): The provider should document complete data for immunizations administered, in their practice, whether valid or invalid.


Training and MCIR Training Checklist • MCIR DQI Business Plan





DATA QUALITY PRINCIPLE #11:

SUPREMACY OF MEDICAL RECORDS

Person medical records are of greater reliability in collecting immunization data than person billing records / CPT codes.

Example(s):

ü MCIR has not accepted billing data since 2003 ü MCIR accepts vaccine (clinical) data


The provider should reference the individual’s clinical immunization record when adding data to the MCIR.


Training and MCIR Training Checklist • MCIR DQI Business Plan




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