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IPRO Data Department 03/01/2016

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Agenda

• Data Submission Requirements
• CROWNWeb Data Management Guidelines
• “Data Managing” by Facilities
• “Data Monitoring” by Network

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Conditions For Coverage

494.180(h) ‐ Standard: Furnishing data and information for ESRD program

• administration. Effective February 1, 2009, the dialysis facility must furnish data and

information to CMS and at intervals as specified by the Secretary. This information is used in a national ESRD information system and in compilations relevant to program administration, including claims processing and reimbursement, quality improvement, and performance assessment.

• Be submitted at the intervals specified by the Secretary;
• (2) Be submitted electronically in the format specified by the Secretary;
• (3) Include, but not be limited to—
• (i) Cost reports;
• (ii) ESRD administrative forms;
• (iii) Patient survival information; and
• (iv) Existing ESRD clinical performance measures, and any future clinical performance standards

developed in accordance with a voluntary consensus standards process identified by the Secretary.

The Conditions for Coverage for End‐Stage Renal Disease Facilities (http://www.cms.hhs.gov/CFCsAndCoPs/downloads/ESRDfinalrule0415.pdf) published in April 2008 outline the need for CROWNWeb on page 20484

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CROWNWeb Data Submission

• CROWNWeb is “National ESRD patient registry”
• Facilities to follow Centers for Medicare and Medicaid Services’

(CMS) requirements for data submission into CROWNWeb using “Data Management Guidelines”

• ESRD Networks are to monitor CROWNWeb data submission

compliance by facilities

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CROWNWeb Supports CMS Goals

• Optimize health outcomes as part of the CMS Quality

Strategy

• Promote high‐quality patient care
• Support ESRD Quality Incentive Program (ESRD QIP)

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CY 2016 and PY 2018

NHSN NHSN Claims CW Claims Claims Claims ICH CAHPS Claims/CW Claims CW CW

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Data Management Guidelines

• Standardized data management Processes
• Separated by tasks and tiers
• Three tasks
• Data Monitoring (Data quality - accuracy, timeliness etc)
• Data Measuring (Data comparison to a criteria)
• Data Managing (Data collection)
• Three tiers
• Tier 1 – enter data directly into CROWNWeb, Facilities, Batch, NRAA-HIE
• Tier 2 – provide technical data reporting assistance, Networks
• Tier 3 – support CMS data reporting needs, Help desk

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“Data Managing” Tasks – Tier 1 (Data Entry)

• Facilities
• Patients
• Personnel
• Clinical
• Action Lists
• Form 2744

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Commonly Used Abbreviations in CROWNWeb

• What is a CCN?
• CMS Certification Number (CCN) =
• 6-digit ESRD Medicare Provider assigned to facility (xxxxxx)
• What is UPI?
• Unique Patient Identifier
• A unique number assigned to a patient record in CROWNWeb when a

patient is admitted

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Facilities

Network

Monitors Facility Attestations

• Send general email
• Send emails to facilities

missing data Facility details

• Enters new facility
• Updates changes
• Tier 1
• Tier 2

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Facilities

• Network can

create a Facility

• Demographics
• Facility Details
• Certification

Information

• Facility can review

and edit limited information

• Is the facility

information accurate?

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Patient Data

• Tier 1

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Patient Data- Batch and Manual Submission

• Tier 1 - Data Managing

DaVita DCI FMC NRAA HIE Independent Facilities

Patent Data submitted- Batch Every Mon Every Tues and Thu Every Mon and Wed Patent Data submitted- Manually Daily

Electronic data interchange (EDI)

Any Time

PART Verification 5th Business day of the following month

• Tier 2 - Data Monitoring: Send email / call “Unverified PART” to

facilities that did not verify PART

PART Verification

• Tier 1 - Verify “PART” by 5th Business day of following month

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PART verification for all patients should be completed by the end of each month – no later than the 5th business day of the following month

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Benefits of PART Verification

• Balances 2744 surveys
• Allows smooth clinical data submission by batch
• Problems related to “First event not new to ESRD” resolved
• Allow timely submission of 2728 and 2746 forms

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Complete 2728 and 2746 Forms

• Tier 2 - Data monitoring
• The Network sends emails with “Missing Forms Report” to facilities on monthly

basis Complete CMS‐2728 and CMS‐2746 Forms within 10 business days of Date Regular Chronic Dialysis Began; no later than 45; CMS‐2746: within 14 days

• f the date of death
• Tier 1 - Data managing

Save & Submit

Save: Can make changes to 2728 and 2746 forms Submit:

• Review before the forms are submitted.
• Once the form is submitted it cannot be changed by facility staff or

network staff.

• A help desk ticket has to be submitted.
• If the information that is being requested changes the benefits

period, CMS contractor can request for records Save: Clinical data is not considered reported if it is in saved format Submit: Once submitted it can be changed until the month is closed

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ICD-10-CM List of Primary Causes of Renal Failure

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Action List Consists of Notifications and Accretions

• Notifications: A discrepancy in patient data between CROWNWeb

and other the Centers for Medicare and Medicaid Services (CMS) data systems.

• Accretions: A patient from another CMS data source that is not in

CROWNWeb Network and Facilities work on action list on a monthly basis

Action List

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Action List

Resolve Notifications and Accretions New or Reassigned: within 15 days of issuance; Under Investigation: within 30 days of issuance

• Tier 2 - Data monitoring : The Network sends emails with

“Outstanding Action Items Report” to facilities on monthly basis

• Tier 1 - Data managing

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About Action Items…..

Dialysis Facility Data System

LDO’s

CROWNWeb

Other CMS DATA SYSTEMS

Submitted Data Rejected Data

Rejected Data Reports

DaVita = Fix it report FMC = Batch Error Report NRAA HIE = CROWNWeb Errors DCI = BRES

Action Items

Updating facility data systems when CROWNWeb “Action Items” are processed leads to less errors on Rejected Data received from your corporation

Fix in your facility data system Fix in your facility data system

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Tier 2 - Patient Data

Week Task Facilities Verifies (NW recommendation) Network Monitors 1 PART 5th Business day Network sends “Unverified PART Report” Emails 2 Missing forms Verified by 10th (see DMG) Network sends “Missing Forms Report” Emails 3 Action list Process Weekly to meet 15 day compliance – update LDO data system (see DMG) Network sends “Outstanding Action Items Report” Emails 4 Data Clean Up First admission not new to ESRD, transient and system discharges etc Network Sends “Data Clean Up Report” Emails (specially during survey period) 4 Clinical data Verifies last week of the month Network sends missing clinical data reports

Network Monthly Data Management Cycle

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Personnel

• CROWNWeb is the authoritative source of emails for Network
• It is provider responsibility to keep the information current
• Personnel information can be updated in CROWNWeb under “Personnel”

tab

• Anyone with access to CROWNWeb can update facility personnel

information.

• Information regarding key staff members (name, Job Description, JOBCODE,

job title, e-mail, and phone number) has to be entered in CROWNWeb.

Add Key Personnel Within 5 business days of staff changes

• Tier 1 - Data managing
• Tier 2 - Data Monitoring: The Network reminds facilities

View Personnel Screen

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Facilities Verify Personnel information

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Job Description JOBCODE Facility Head Nurse/Nurse Supervisor FHNNS Facility Social Worker FSW Facility Dietitian FDIET Facility Medical Director FMD Facility Administrator FADM Facility Nephrologist FNEPH Facility Data Contact FDC

Key personnel Info – complete all the information Positions – create as many positions as required. For Personnel with scope over several facilities, remove the position. Do not delete the personnel or inactivate them. One can add and remove as many positions as possible. Personnel Contact Info – Email is required.

Key staff members with JOBCODE

Personnel Details Screen

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• Hemodialysis clinical data
• Peritoneal dialysis clinical data
• Vascular access data
• Data for each month is due in CROWNWeb by the end of the

2nd month

• Batch data submitted by Large Dialysis Organizations

Clinical And Vascular Access Data

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Tier 1 - Clinical Data

DaVita DCI FMC NRAA HIE Independent Facilities Clinical Data Uploaded /submitted manually Full clinical data submission on 15th day of the following month or next business day Full clinical data submission

• n Second

Tuesday in the following month Full clinical data submission

• n 2nd

Monday in the following month As soon as facilities submit data to NRAA HIE. By last day

• f the

month Clinical data completeness verified by every facility After 25th Last week Last week Last week Last week

Batch and EDI data submission

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Tier 2 - Clinical Data

Week Task Facilities Complete Network Monitors 1 PART 5th Working day Network sends “Unverified PART Report” Emails 2 Missing forms Verified by 10th (see DMG) Network sends “Missing Forms Report” Emails 3 Action list Weekly – update LDO data system (see DMG) Network sends “Outstanding Action Items Report” Emails 4 Data Clean Up First admission not new to ESRD, transient and system discharges etc Network Sends “Data Clean Up Report” Emails (specially during survey period) 4 Clinical data Verifies last week of the month Network sends missing clinical data reports

Network Monthly Data Management Cycle

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Help desks

CROWNWeb Education Lead

FMC Help Desk: 866-491-8167 NRAA Help Desk Form (http://www.for mstack.com/form s/?1228399- P1hy2crrdK) CROWN Help desk 866-288-8912 qnetsupport- esrd@hcqis.org

Da DaVit ita DCI DCI FMC NRA RAA A HIE IE All All Facil ilit ities ies

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2744 Deadlines

• January 1, 2016 - February 15, 2016: Regenerate and

begin review, data cleanup and initial submission of CMS- 2744 survey in CROWNWeb for year 2015

• April 1, 2016: Final due date for submission to the ESRD

Network for approval

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2744 Process

• Step 1:
• In CROWNWeb, click on Form 2744 tab. Click “Search”. Enter

your facility Medicare Number and click on “Go” go to populate the facility name. Enter the survey year as “2015”. Then click “Submit”.

• Once the form opens up, enter treatment and staffing
• information. Verify Vocational Rehabilitation information
• When the form is completed click “submit”.
• Step2: The Network verifies the data and then “Accepts” the form.
• Step3: If the data is incomplete the Network will “Reject” the form.
• Step4: If the data is complete, the Network will submit the form as

“Finalized”.

Access to CROWNWeb

• Security Awareness Training (SAT)
• Create a QualityNet Identity Management System (QIMS)

account

• Part A - general QIMS account information
• ESRD Application Access Form (EAAF)
• Defines a user’s CROWNWeb role and scope
• Defines a users QIP role and scope

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QualityNet ESRD Facilities tab

You can register for a QIMS account through this page.

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Three Types of QIMS Account

• Security Official (SO) – Two user ID’s
• End User Manager (EUM) – One user ID
• End Users – One user ID
• Each facility should have one EUM and one SO at all times
• Each facility should have one “ Facility Point of Contact”
• Create a “Facility Point of Contact” for QIP
• Each facility has one person with access as “Facility Point of Contact” to print

“Performance Score Certificate”

http://esrd.ipro.org/initiatives/data-systems-and-reporting/crownweb-2/

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PART A Application

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Part A Form Signature Requirements

• Applicant cannot sign the form as their own EUM or SO
• If the applicant is the first user at the facility,
• Applicant should be an SO
• PART A form has to be notarized

When completing the online PART A application

• Applicant should select Master Manger
• Applicant should select Master Security Official
• Applicant is the first EUM / second user at the facility,
• PART A form can be signed by facility SO
• Select facility SO and Master Manager when completing the online

PART A application

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EAAF Form

Login to CROWNWeb

Click ESRD Facilities

www.qualitynet.org

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CW Login Screen

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CMS Warning

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Two Factor Authentication (TFA)

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How to change the way TFA code is received?

• Go to www.qualitynet.org
• Click ESRD tab
• On left hand side click Manage QIMS account
• You will be brought to a screen identical to CW login screen; Enter your

CW id and password

• Click Accept on the warning screen
• Click Profile tab, then Account Attributes
• Scroll down to Preferred TFA Method and select method: Email,

Phone number or Cell phone number

• At the bottom of the screen enter your CW password & click Save

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QIMS Home Page

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*EUM approves other users *

Profile Screen

• Change

password

• Setup/update

authentication questions To change TFA

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Account Attributes Screen

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Account Attributes Screen (cont’d)

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CROWNWeb Useful Features

• Wildcards
• Breadcrumbs

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What is a Wildcard?

• A wildcard is a symbol entered into a field when one is uncertain of

search criteria

• CW allows a percent (%) for wildcard searching in fields marked

with a percent (%)

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Breadcrumbs

A breadcrumb will help get back to a previous screen

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Edit information

• CROWNWeb always opens as “View only” mode.
• Any screen that gives the ability to edit will have an

“Edit…”button in the grey bar to the top left of each page

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QualityNet Help Desk

If you need assistance with the registration process contact the QualityNet Help Desk at: 866-288-8912 (Monday - Friday 8am to 8pm EST) or via e-mail at qnetsupport-esrd@hcqis.org

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Reports

• Reports
• Patient Forms: Download blank forms and Instructions
• Run Audit Forms Report
• Run Saved forms report
• Run Notification and Accretions Reports
• Run some clinical data reports
• My Reports
• Will show the reports that have been generated

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http://mycrownweb.org

• Admit a New Patient
• View and Verify PART Data
• Notifications and Accretions – Facility Role
• Facility
• Add, Edit, and Delete Facility Personnel
• Completing the CMS-2728 Form
• Completing the CMS-2746 Form
• Completing the CMS-2744 Form – Facility Role

http://mycrownweb.org/education/crownweb-training-videos/ http://mycrownweb.org/education/training-courses/

Training and Education

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Tutorials

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NHSN Data Management

• Dialysis Module
• Annual Survey - annually
• Dialysis Event Data submission – quarterly but the Network

recommends monthly

• Data quality Checks - quarterly
• Run CMS - ESRD - QIP report – quarterly
• Healthcare Personnel Influenza Vaccination
• Reporting plan
• HCP vaccination data

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DialysisData.org

• Facility Master Account UserId and Password
• Create users
• Annually enable users
• Facility User accounts
• Comment on DFC and DFR
• Download DFR and DFC reports

Common CMS Systems / Roles

Role System System Description Related Systems Login ID Looks Like Suggested Staff to have access

NHSN Administrator NHSN Report Dialysis Events; Staff Vaccinations

Email (+SAMS card for code) NM, RN, AA

QIMS

• Security Official;
• End User Manager

QIMS Approve, Disable and Edit QIMS User Accounts CROWNWeb; QIP 1.0.0

xx1111 SW, AA (SO) NM (EUM) MD

CROWNWeb

• Facility Administrator
• Facility Editor and/or
• Facility Viewer

CROWNWeb CMS Data System for Facility, Patient and Clinical Data QIMS; QIP 1.0.0

xx1111 NM, MD SW, AA

QIP 1.0.0

• Point of Contact
• Facility Viewer

QIP 1.0.0 View, Download and Comment on PSRs and PSCs QIMS; CROWNWeb

xx1111 NM, AA, MD (Facility POC)

Dialysis Data.org

• Master Account Holder

DialysisData.

• rg

Enable/Disable Accounts; Add/Remove Permissions

CCN NM DialysisData.org

• Regular User

DialysisData .org View/Edit/Comment on DFR and QDFC Email MD, NM

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Data Submission Final Thought

• CROWNWeb Data – Follow data management guidelines
• Infection data in NHSN - End of quarter after each quarter

Data may come from anywhere – each facility is responsible for the accuracy and completeness of their own data

Contacts

Victoria Cash, MBA, BSN, RN Executive Director vcash@nw9.esrd.net Jaya Bhargava, PhD, CPHQ Interim Operations Director jbhargava@nw9.esrd.net Debbie DeWalt, MSN, BSN, RN Assistant Director, Quality Improvement ddewalt@nw9.esrd.net Andrea Bates, MSW Patient Services Director abates@nw9.esrd.net Kaszowski, Michelle

• Sr. Program Support Coordinator

MKaszowski@nw9.esrd.net Wendy Cable, RN, BA Information Systems Director Wcable@nw9.esrd.net TBD Quality Improvement Coordinator TBD@nw9.esrd.net TBD Community Outreach Coordinator TBD@nw9.esrd.net

3201 Enterprise Parkway, Suite 201, Beachwood, OH 44122 Phone: (203) 387-9932 Fax: (203) 389-9902

IPRO ESRD Network of The Ohio River Valley (Network 9)

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IPRO ESRD Program Website http://esrd.ipro.org

For more information

IPRO ESRD Program http://esrd.ipro.org

CORPORATE HEADQUARTERS 1979 Marcus Avenue Lake Success, NY 11042-1002 www.ipro.org