mhs data overview m2 foundations course

MHS Data Overview

M2 Foundations Course

FOR OFFICIAL USE ONLY2

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.

Objectives• Attendees can:

1. Describe the major data collection systems in the MHS.

2. Describe data feeds from these systems to central repositories.

3. Describe the MDR and its role in feeding MHS data marts.

4. Identify key strengths of using MDR-based data vs. local data.

3FOR OFFICIAL USE ONLY

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)


Good News, Bad News• Good news:

• The MHS has made significant advances in automation systems

• We have tons of data that other health systems and providers wish for!

• Bad news:• Some quality issues with the data• Very cumbersome development process

• This presentation will highlight available data and discuss strengths and weaknesses along the way!


Kinds of Data The MHS Collects Centrally

Type of Data Direct Care

Purchased Care

Other

Person Data (Elg, Enroll)Deployment InformationInpatient Hospital RecordsProfessional Records OP Only

Lab/Rad Proc CodesLab/Rad ResultsVital SignsPharmacy PrescriptionsInpatient PharmacyCase Management RecordsDental

And more and more and more 6FOR OFFICIAL USE ONLY

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.


Inpatient Record Data Flow (Oct 98)

MTF

CHCS

AIR Force(uses

AFVAL edits)

Army(uses PASBA

edits)

Navy(none, may use PASBA edits)

DataMart

DMIS Processor

RCMASV1

RCMASV2

DMIS-SS

CEIS IDB(edit checks

include parser & logical edits)

LegacySAS


Inpatient Record Flow (Apr 99)

M

T

F

C

H

C

S

AIR Force(uses VRI

AFVAL edits)

Army(uses PASBA

edits)

Navy(none, may use PASBA edits)

DataMart

DMIS Processor

DMIS-SS

CEIS IDB(edit checks

include parser & logical edits)

RCMASV1

RCMASV2

FeedNode

IDBR(min edits) RPU

(min edits)

RLP(min edits)

RLPSAS

EDWETL

EDW Stars(data transformed to FAM-D standard)

LegacySAS

Until 6/30/99

ARSPASBA9

FOR OFFICIAL USE ONLY

Inpatient Record Flow (Today)

M

T

F

C

H

C

S

FeedNode

Other Data Marts

MDR

Simplicity……….

M2


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 Service-specific systems.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!


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.


Example of MPI ApplicationPerson 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

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

As received After MDR Processing


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.


ExamplePerson 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


Person ID Enroll MTF Type of Care Service Date DOB

1111111111 Bethesda Admission 10/5/2011 10/5/2011




As received After MDR Processing

. Person-identifier was not available when MTF submitted original record. Patient was also not enrolled at that time. 16


• 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!

MDR Enhancements


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


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.


• 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.

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:

MDR Enhancements

22

Person MTF Appt Date Provider Diagnosis Record ID

A 0091 07/01/2010 Doc Jones Abdominal Pain X

Person MTF Related Record ID

Ordering Clinic

Service Date Procedure

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

MTF Labs/Rads:


• 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

MDR Enhancements

23

Associated Professional Records:

Person Admitting TED # Begin Date End Date MS-DRG Diagnosis Primary Procedure

A X 10/10/10 10/12/10 619 MORBID OBESITY LAPAROSCOPIC GASTROENTEROSTOMY

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;


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.


Basic Data Flow

TED MDR Feed Node

Data sent to MDR 24/7

CHCS/AHLTA

DEERS

PDTS

MDR File Storage & Limited Access

M2 and Data Marts

Batches

Others User Access in Data Marts

Weekly Monthly


Survey of Available Data in M2


Person Data


Person DataThere 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.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.


Beneficiary Data

• 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.

Data in DEERS


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

Name Person ID Sponsor SSNRelation to

Sponsor Bencat Elg Start Date Elg Stop DateJoe Smith A A Self Reservist 3/1/2005 6/1/2006Joe Smith A B Spouse AD Family 6/2/2006 6/2/2026



Joe’s data between 2005/2006 and Oct 14, 2011

Joe’s data beginning Oct 15, 2011


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!


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”.


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!


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!


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).


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.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


Navy Eligible Population Profile

BencatNavy

SponsoredMarine

SponsoredNavy 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%

Total 1,795,330 765,324 292,283 9,691,255 29%

• All data are from M2 DEERS Population Summary and represent December 2011.• Navy/Marine Sponsored patients represent a third of the Active Duty Population


Eligible Population – Trend

•All data are from M2 DEERS Population Summary40


Navy and Marine Population

Age GroupActive 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

H: 65+ 754 262,939 293,250 29 556,972

Z: UNK 35 8 23 66

Total 679,570 624,097 991,227 558,043 2,852,937

•All data are from M2 DEERS Population Summary and represent December 2011.41


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.42


Prime Enrollment Trend by Service of Enrolling MTF

One of these lines doesn’t look like the others!Source: M2 Relationship Summary

43


Navy Enrollment 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

6 Parent MTFs represent half of Prime Enrollment at Navy MTFs

Source: M2 Relationship Summary44


TRICARE Plus Enrollees at Navy MTFs

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%

84% of Navy MTF T-Plus Enrollees are also TFL

Source: M2 Relationship Summary


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.


Top DMISIDs with Navy/Marine AD Enrollees Deployed

DMISID DescriptionAD Enrolled to

OP ForcesAD Not Enrolled Prime

Grand Total

6311 Op Forces – Lejeune 10,676 10,6766301 Op Forces – Pendleton 6,923 6,923NONE N/A 5,822 5,8226303 Op Forces - San Diego 2,997 2,9976320 Op Forces - Pearl Harbor 2,902 2,9026317 Op Forces – Portsmouth 2,532 2,5326304 Op Forces - 29 Palms 2,120 2,1201170 NBHC Bahrain 2,030 2,0306312 Op Forces - Cherry Pt 1,635 1,6356318 Op Forces – Bremerton 1,607 1,6076307 Op Forces – Jax 1,236 1,236

Source: M2 Relationship Summary 47FOR OFFICIAL USE ONLY

Direct Care Health Care Data


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).


Composite Health Care System and AHLTA


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.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.


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

A 0417 7/1/20091/31/202

5

A 51971/13/201

23/22/202

3

PersonEnroll MTF

Start Date

Stop Date

B 00066/17/201

1 9/6/2012

B 01068/23/201

1 9/6/201253FOR OFFICIAL USE ONLY

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.


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 office-based 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.


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!


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.Name Person ID Sponsor SSNRelation to




Joe’s data between 2005/2006 and Oct 14, 2011

Joe’s data beginning Oct 15, 2011


CHCS and AHLTA Data Flows

• CHCS is the data capture point for MTF:

• Inpatient Admissions• Appointments• ~20% of ambulatory

encounters• Laboratory• Radiology• Pharmacy• Appointment

• AHLTA is the data capture point for MTF:• ~80% of ambulatory

encounters• Vitals• Linkages of

diagnosis/procedures• Historical Procedures• Immunizations• Other clinical data


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


Coding Editor

MDR

CHCS ADMCHCS Appt Module

APPT

CDR/CDM

ADM + AHLTA Records are in CAPER file for MDR

Ambulatory Data Collection at MTFs AHLTA

APPT

Coding edits do not flow to CDR/CDM

CAPER


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 Encounter Record (CAPER) (used to be SADR)

Outpatient visit, t-con or inpatient rounds records Weekly

Ancillary Lab, Rad and Rx Procedure Records Monthly

Medical Home Enrollment CHCS-reported Medical Home records Monthly

Detailed CHCS Data Products in the MDR

61Will discuss other feeds from CDR in a later sessionFOR OFFICIAL USE ONLY

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)


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)


Top MS-DRGs performed at Navy Hospitals

64

MS-DRG Description Count NORMAL NEWBORN 10,911 VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES 10,337 NEONATE, BIRTHWT >2499G, W/O SIGNIF O.R. PROC, W OTHER PROB 5,163

CESAREAN SECTION W/O CC/MCC 2,818 VAGINAL DELIVERY W COMPLICATING DIAGNOSES 2,464 CESAREAN SECTION W CC/MCC 1,992 CHEST PAIN 1,569 ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE >17 W/O MCC 1,250 NEONATE, BIRTHWT >2499G, W/O SIGNIF O.R. PROC, W MAJOR PROB 1,110 UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC/MCC 1,065

These ten DRGs make up about half of Navy’s inpatient production!

•Source: M2 Inpatient Admissions Detail (SIDR).


Multiple Direct Care Admissions for a Single Patient

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

65

Person is an unenrolled active duty family member

•Source: M2 Inpatient Admissions Detail (SIDR).


Case Mix at U.S.-based Navy Inpatient MTFs

Tmt DMIS ID Tmt DMIS ID Name RWPs Disp Case Mix

0067 WALTER REED NATL MED CENTER 3,951 3,542 1.120029 NMC SAN DIEGO 4,201 4,661 0.900124 NMC PORTSMOUTH 3,952 4,412 0.900104 NH BEAUFORT 112 128 0.880038 NH PENSACOLA 577 865 0.670126 NH BREMERTON 449 718 0.630039 NH JACKSONVILLE 822 1,332 0.620091 NH CAMP LEJEUNE 1,194 2,071 0.580024 NH CAMP PENDLETON 907 1,709 0.530030 NH TWENTYNINE PALMS 209 472 0.440028 NH LEMOORE 75 185 0.400127 NH OAK HARBOR 109 301 0.36

•Source: M2 Inpatient Admissions Detail (SIDR), FY 2011. 66FOR OFFICIAL USE ONLY

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)


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.


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)


Navy-Wide Number of Referrals

70

ACV Group ADFM RET OTH AD UNK Total

Desig Prov 152 195 50 17 414

Other 16,198 18,578 29,924 22,212 86,912

Overseas Remote 244 11 981 1,236

Plus 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

Grand Total 403,853 207,218 261,422 933,743 22,212 1,828,448

•Source: M2 Referral File; FY 2011.


Example of Linked Referral and Outpatient Data

Person Referral Date

Referring Provider

Begin Date End Date Refer to

ClinicReferral Number

A 08/03/2010 Prov A 08/03/2010 08/03/2011 BAB X

Referral Record

Person Appt Date Clinic Referral

NumberA 12/04/2010 BAB XA 01/03/2011 BAB XA 02/01/2011 BAB X

Associated Encounters



• 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.


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)


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


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.


Top DRGs performed at Navy Hospitals

76

MS-DRG Description Count VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES 10,337

CESAREAN SECTION W/O CC/MCC 2,818 VAGINAL DELIVERY W COMPLICATING DIAGNOSES 2,464 CESAREAN SECTION W CC/MCC 1,992

Delivery DRGs from Navy Top 10 List

CAPERs recorded for professional services in MEPRS A Codes CPT/HCPCS Count 59409: Vaginal Delivery and Postpartum Care 10,229

59514: C/Section Only 4,015 59410: Vaginal Delivery Only 386 59612: VBAC Only 265 59400: Complete Obstetrics Package (all-prenatals/PPM) 166 Etc…

•Source: M2 Inpatient Admissions Detail (SIDR) and Professional Encounters Detail (CAPER); FY 2011


Professional Services Records•Comprehensive Professional Encounter Record (CAPER)

• 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 Encounters Detail (CAPER)” in M2.

• Summary also available.77


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


Professional Encounters

Record ID Service Date

A 06/01/10

B 06/08/10

C 06/05/10

D 06/18/10

79

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

“Kept” Appt Records

Record ID Service Date

A 06/01/10

B 06/08/10

Inferred CAPERs have no Diagnosis or Procedure codes

CAPERs

+

MDR and M2 Professional Encounter Records


Top 10 Clinics at Navy Hospitals and Clinics for FY 2011, based

on encounters

80

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 2011FOR OFFICIAL USE ONLY

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 81

Taken from an M2 Canned Report FOR OFFICIAL USE ONLY

Frequent Flier Report

Person Clinic Enc Date Diagnosis Estimated Cost

A BIA 11/05/09 MIGRAINE,UNSP,WO INTRAC WO MIG $1,447.39

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

82

A BIA 10/29/10 CHRONIC PAIN SYNDROME $448.37

Totals 28 Encounters 19 Diagnoses $15,297.30

•••

Example taken from an M2 Canned ReportFOR OFFICIAL USE ONLY

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.


84

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


Example of Linked Case Management Records

From Case Management File

From Case Management Corporate Report

Patient Acuity Start Stop CMA 2 10/1/2011 2/5/2012 #1

Patient Data Type Beg End CM AcuityA TED-N ER 10/15/2011 10/15/2011 #1 2A TED-N ER 10/20/2011 10/20/2011 #1 2A TED-I Admission 10/22/2011 11/22/2011 #1 2A TED-N Doctor Bill 10/22/2011 10/22/2011 #1 2A PDTS Script 11/23/2011 11/23/2011 #1 2



• 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


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.


88

Coding Creep Example

MHS Worldwide Average (non ERs), October 2005 through January 2011

Average E&M Code Intensity

88


89

Coding Creep ExampleOne Medical Examination Clinic. . .

October 2005 through January 2011 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

90471Administration of a Single Vaccine 906 48

90471Administration of a Single Vaccine 907 15

90473Administration of a Single Vaccine - Oral 906 17

90801 Psychiatric Eval (covers up to 24 hours) 52 159


•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.

Laboratory and Radiology Data Records


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


Lab and Rad Services at Navy MTFs

93

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


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 radiologists94


Example of Lab History

Person MTF Clinic Encounter Date Procedure Primary Dx

A 0058 BGA 08/18/10 GLYCOSYLATED HEMOGLOBIN TEST



A 0058 BAA 09/18/10 GLYCOSYLATED HEMOGLOBIN TEST

A 0064 BHG 10/13/10 GLYCOSYLATED HEMOGLOBIN TEST

95

Can usually be linked to visit where test was ordered for information about what diagnoses may have led to the test order.


Example of Linked Outpatient and Lab/Rad Data

Person MTF Appt Date Referring Clinic Diagnosis Record ID

A 0110 07/01/2011 BAG Abdominal Pain 22652870

CAPER

Person MTF Related Record ID

Ordering Clinic

Service Date Procedure

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

Associated Lab/Rad data



• 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.


MEPRS• MTF Accounting System

• 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. • MEPRS Contains:

• Expense data from Service systems• Workload data from CHCS, primarily• Manpower data from DMHRS

• Available only at MTF, Month, Year and MEPRS Code level.


Navy MEPRS Workload and FTE Summary - 2011

MEPRS Code

Average Available

Provider FTEs Bed Days DispositionsRx 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


Largest Navy MTFs (by FY 2011 MEPRS $)

Name Total Exp% of All

NavyCumulative

%NMC SAN DIEGO 939,943,300 18% 18%

WALTER REED NATL MIL MED CEN 806,693,504 15% 33%NMC PORTSMOUTH 806,367,625 15% 49%NH JACKSONVILLE 280,307,588 5% 54%NH CAMP PENDLETON 279,086,160 5% 59%NH CAMP LEJEUNE 242,465,456 5% 64%NH PENSACOLA 239,806,816 5% 69%NH BREMERTON 170,396,460 3% 72%NH OKINAWA 133,421,055 3% 74%NH YOKOSUKA 129,861,050 2% 77%


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.


Purchased Care Claims Data


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


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


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 cover partial stays, includes multiple diagnoses and procedures

•Sent and processed monthly in the MDR, data mart extracts prepared.


Top DRGs for Navy MTF Enrollees in the Private Sector – Acute Care Only

(FY2011)

106

MS-DRG Description AdmissionsHospital

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 1,779Source: M2 Purchased Care Institutional DetailNote impact of Region South enrollment policy


Average Cost of Hospital Care for Navy MTF Enrollees

Program Admissions Total Hosp Paid Avg Hosp Paid

Plus 3,049 3,775,662 1,238

Prime 20,412 183,760,018 9,003

Acute Care -- Purchased Care

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 107FOR OFFICIAL USE ONLY

Multiple Related Admissions -- Private Sector

Person Hosp MSDRG Description Adm Date Disp Date LOS

A X 619 O.R. PROCEDURES FOR OBESITY W MCC 03/18/11 03/20/11 2

A X 862 POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC 03/26/11 04/01/11 6

A X 603 CELLULITIS AGE >17 W/O MCC 04/28/11 04/30/11 2


Example of Linked Inpatient Data

Person Admitting TED No. Begin Date End Date MS-

DRG Diagnosis Primary Procedure

A X 10/10/11 10/12/11 619 MORBID OBESITY

LAPAROSCOPIC GASTROENTEROSTOMY

Institutional TED

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;

Associated Non-Institutional TEDs


110

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

Total for all three records 1 99 3


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 record represents one provider and one procedure code•Sent and processed monthly in the MDR, data mart extracts prepared.


Navy Prime Enrollee Places of Care

112

Place Description RVUs Amt Paid

11 Office 5,050,436 166,437,180

22 Hospital Outpat Dept 535,199 128,031,307

19 Pharmacy 113,454,048

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

95% of TED Non-Institutional Costs for Navy Prime enrollees were in these places of care.

Source: M2 Non-Institutional Detail, FY11.FOR OFFICIAL USE ONLY

Example of Claims when Patient has Surgery

Person Service Date Place Provider Specialty Procedure

A 02/09/11 ASC Anesthesiology ANESTH,SURG ARTHROSCP SHOULDER

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 SHOULDER ARTHROSCOPY/SURGERY

A 02/09/11 ASC Orthopedic Surgery SHOULDER ARTHROSCOPY/SURGERY

A 02/09/11 ASC Physician’s Assistant SHOULDER ARTHROSCOPY/SURGERY

A 02/10/11 Office Clinic or other group practice THERAPEUTIC EXERCISES

A 02/13/11 Pharmacy Pharmacy PRESCRIPTION DRUGS

113These are not duplicate records; they are indications that both the facility and the providers were paid.FOR OFFICIAL USE ONLY


• 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


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.


116

Rec ID E&M Proc1 Proc 2 Proc3 Proc4 Prov1 Prov2 Prov3 Encounters

A 99392 99173 90471 C* D* 1

Example CAPER

Rec ID

Line Item Provider Procedure # Line

Items# Visits

A 1 C* 99392 1 1B 1 D* 99173 1 1B 2 D* 90471 1 1

Record A, as it would appear if the care had been delivered in the private sector

Direct and Purchased Care Provider Workload

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


117

Direct and Purchased Care Provider Workload

•Procedure Code represents 15 minutes of PT

• 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

IDLine Item

NumberPerson 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

118

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.

Rec ID

Line Item Number Person Beg Date End Date Procedure Place # Line

Items#

Services#

Visits1 1 A 12/9/009 12/9/2009 59510 21 1 1 02 1 A 1/16/2010 1/16/2010 59400 21 1 1 03 1 A 1/9/2010 1/9/2010 59410 21 1 1 0

Example TED Records for Global Maternity Procedures

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.


Pharmacy Data


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.


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. 121FOR OFFICIAL USE ONLY

Navy MTF Share of Prescriptions for Navy

Enrollees (Prime and Plus)

122

Year MTF Retail Mail VA Total MTF Share2002 7,598,878 412,550 36,914 8,048,342 94%2003 7,205,752 455,600 26,124 7,687,476 94%2004 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 2011FOR OFFICIAL USE ONLY

Top Drug Classes for Navy MTF Enrollees

123

Code Therapeutic Class ADFM RET OTH AD Total280804 NSAIDs 182,290 126,722 120,523 353,360 782,895280808 Opiate Agonists 137,782 73,398 88,892 256,403 556,475281604 Antidepressants 117,019 44,804 81,833 126,239 369,895040800 Antihistamines 121,858 36,638 61,143 74,659 294,298280892 Analgesics 102,997 14,422 27,360 80,499 225,278240608 HMG-COA Reductase Inhibs 9,967 103,102 72,616 36,686 222,371562836 Proton Pump Inhibitors 34,351 62,619 59,858 57,549 214,377

Source: M2 Pharmacy (PDTS); FY 2011FOR OFFICIAL USE ONLY

Drug History Example

124

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 10/07/11 Oxycontin 5 10 10 MG $19.74 0504692

Totals 1 year 737 days supply

1593 pills

63 MG (avg) $13,783.83

15 pharmacie

s

•••

A 03/25/10 Oxycontin 30 30 80 MG $338.31 0576477

A 03/30/10 Oxycontin 7 14 80 MG $157.76 0595047

•••


125

CAPER and PDTS LinkCAPER/SADR ENCOUNTER

Treatment DMIS ID 0089

Record ID 15513083Procedure 1 95010-Percutaneous Tests, Imm

ReactionProcedure 2 94760-Pulse OximetryProcedure 3 94010-SpirometryE&M Code 99245-Office ConsultDiagnosis 1 99560-Anaphylacti Shock; Food

NOSDiagnosis 2 9957-Adverse ReactionDiagnosis 3 4779-Allergic RhinitisDiagnosis 4 9950-Anaphylactic ShockMEPRS 3 Code BAB-AllergyProvider ID Prov #1

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)



• Strengths:• Only source for person level, detailed

pharmacy data• Much better pharmacy cost data than other

sources.

• Weaknesses:• Limited to outpatient prescriptions


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.


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.


mhs data overview m2 foundations course

Documents