Depression Care Measures 2013 Direct Data Submission

DATA COLLECTION GUIDE Direct Data Submission Depression Care Measures 2013 (02/01/2012 to 01/31/2013 Dates of Service)

Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. 1

Table of Contents Measure Specifications ....................................................................................... 3 Summary of Changes .......................................................................................................... 4 Table 1: ICD-9 Diagnosis Codes for Identifying Major Depression or Dysthymia............... 6 Table 2: ICD-9 Diagnosis Codes for Identifying Patients Meeting Exclusion Criteria ......... 7 Measure Logic/Flow Chart for Patients Who Are Not Indexed .......................................... 9 Measure Logic/Flow Chart for Patients Who Are Indexed ............................................... 10

Data Elements and Field Specifications ............................................................. 11 Direct Data Submission Instructions ................................................................. 19 Summary of Changes ........................................................................................................ 20 About Direct Data Submission .......................................................................................... 20 DDS Participation Requirements ...................................................................................... 21 Confidentiality and HIPAA for Direct Data Submission .................................................... 22 Overview of the Process and Timelines ............................................................................ 23 Resources to Get You Started ........................................................................................... 26 Step 1: Registration on the MNCM Data Portal................................................................ 27 Step 2: Identifying the Patient Population (Denominator) .............................................. 28 Clinic Level Population Counts .............................................................................. 32 Patient Level Data ................................................................................................. 34 Step 3: Data Collection...................................................................................................... 36 Step 4: Data Quality Checks .............................................................................................. 42 Step 5: Date File Creation and Data Submission .............................................................. 46 Step 6: MNCM Validation of Submitted Data ................................................................... 52 Step 7: DDS Results ........................................................................................................... 54

Appendices ...................................................................................................... 56 Appendix A: About MN Community Measurement and Measure Development ............ 57 Appendix B: Explaining the Depression Measures & Submission to Providers ................ 60 Appendix C: Suite of Available Depression Care Measures .............................................. 62


Depression Care Measures 2013 Direct Data Submission (02/01/2012 to 01/31/2013 Dates of Service)

Measure Specifications


Depression Care Measures 2013 Direct Data Submission Measurement Specifications Summary of Changes

Date of birth clarification

Description

A measure of the percentage of patients who have reached remission at six months (+/- 30 days) after being identified as having an initial PHQ-9 score > nine. Remission is defined as a PHQ-9 score less than five.

Methodology

Population identification is accomplished via a query of a practice management system or Electronic Medical Record (EMR) to identify the population of eligible patients (denominator). Data elements are either extracted from an EMR system or abstracted through medical record review.

Added language to clarify date of birth range. Please note the changes in the denominator section.

Full population data is required. Rationale

The priority aim addressed by this measure is to improve the outcomes of treatment for patients with major depression or dysthymia. The Center for Disease Control and Prevention states that 15.7% of people report being told by a health care professional that they had depression at some point in their lifetime. Persons with a current diagnosis of depression and a lifetime diagnosis of depression or anxiety were significantly more likely than persons without these conditions to have cardiovascular disease, diabetes, asthma and obesity and to be a current smoker, to be physically inactive and to drink heavily. According to National Institute of Mental Health (NIMH), 6.7 percent of the U.S. population ages 18 and older (14.8 million people) in any given year have a diagnosis of a major depressive disorder. Major depression is the leading cause of disability in the U.S. for ages 15 - 44. Additionally, dysthymia accounts for an additional 3.3 million Americans. Suicide rates for Minnesotans are 10.4 per 100,000 or 1.3 suicides per day, with the highest rates among the following groups: males (four times greater than females), ages 30 to 49 years, and nonHispanic whites.

Measurement Period*

Measurement period will be a fixed twelve-month period: 02/01/2012 to 01/31/2013. In order to collect data to calculate remission at six months, you will need to track patient index visits between 07/01/2011 to 06/30/2012.

*PLEASE NOTE: The measurement period refers to the summary data submission (SDS) measurement period. If you have been submitting DDS to MNCM in the past, you can disregard this measurement period as the MNCM Data Portal tracks patients for you. Please refer to Appendix C for the suite of Depression Care Measures available to medical groups submitting data via the DDS process.


Depression Care Measures 2013 Direct Data Submission Measurement Specifications Denominator

Patient who meets each of the following criteria is included in the population: 

Patient was age 18 or older at the index visit (date of birth was on or prior to 02/01/1994).



Patient had visit or contact with an eligible provider in an eligible specialty between 07/01/2011 to 06/30/2012.



Patient had an initial PHQ-9 score > nine.



Diagnosis of Major Depression or Dysthymia; ICD-9 diagnosis codes include: 296.2x, 296.3x and 300.4. o

For primary care providers, these diagnosis codes can be in any position.

o

For behavioral health providers, the depression or dysthymia diagnosis codes need to be listed as the primary diagnosis. This is to insure that the patient is primarily being treated for major depression and does not have other more serious psychiatric conditions like psychoses, schizophrenia or bipolar disorder with underlying depression.

Eligible specialties: Family Practice (Includes General Practice), Internal Medicine, Geriatric Medicine, Psychiatry, and Behavioral Health professionals (if physician on site).

Eligible providers: Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Nurse Practitioner (NP), Clinical Nurse Specialist (CNS). If a physician is on site, then Licensed Psychologist (LP), Licensed Independent Clinical Social Worker (LICSW), Licensed Professional Clinical Counselor (LPCC), Licensed Marriage & Family Therapist (LMFT). Allowable exclusions

Numerator



Patient was a permanent nursing home resident during the measurement period.



Patient was in hospice at any time during the measurement period.



Patient died prior to the end of the measurement period.



Patient has diagnosis of Bipolar Disorder (ICD-9 diagnosis codes listed below).



Patient has diagnosis of Personality Disorder (ICD-9 diagnosis codes listed below).

The number of depression patients with an initial PHQ-9 score > nine whose PHQ-9 score at six months (+/- 30 days) is less than five.


Depression Care Measures 2013 Direct Data Submission Measurement Specifications Coding Conventions Used in MN Community Measurement Documentation Unless otherwise noted, codes are stated to the minimum specificity required. For example, if a code is presented to the third digit, any valid fourth or fifth digits may be used. When necessary, a code may be specified with an “x,” which represents a required digit; for example, ICD-9-CM diagnosis code 296.3x indicates a fifth digit is required, but the fifth digit could be any number allowed by the coding manual. This coding convention is used to describe ranges of codes, please refer to the tables included for the complete list of codes.

Major Depression and Dysthymia Diagnosis Codes Table 1: ICD-9 Diagnosis Codes for Identifying Major Depression or Dysthymia ICD-9 Diagnosis Code ICD-9 Diagnosis Code Description 296.2 Major depressive disorder single episode 296.20 Major depressive affective disorder single episode unspecified degree 296.21 Major depressive affective disorder single episode mild degree 296.22 Major depressive affective disorder single episode moderate degree 296.23 Major depressive affective disorder single episode severe degree without psychotic behavior 296.24 Major depressive affective disorder single episode severe degree specified as with psychotic behavior 296.25 Major depressive affective disorder single episode in partial or unspecified remission 296.26 Major depressive affective disorder single episode in full remission 296.3 Major depressive disorder recurrent episode 296.30 Major depressive affective disorder recurrent episode unspecified degree 296.31 Major depressive affective disorder recurrent episode mild degree 296.32 Major depressive affective disorder recurrent episode moderate degree 296.33 Major depressive affective disorder recurrent episode severe degree without psychotic behavior 296.34 Major depressive affective disorder recurrent episode severe degree specified as with psychotic behavior 296.35 Major depressive affective disorder recurrent episode in partial or unspecified remission 296.36 Major depressive affective disorder recurrent episode in full remission 300.4 Dysthymic disorder


Depression Care Measures 2013 Direct Data Submission Measurement Specifications Codes Used to Identify Patients who Meet Exclusion Criteria Table 2: ICD-9 Diagnosis Codes for Identifying Patients Meeting Exclusion Criteria ICD-9 Diagnosis Code ICD-9 Diagnosis Code Description 296.00 Bipolar I Disorder, Single Manic Episode, Unspecified 296.01 Bipolar I Disorder, Single Manic Episode, Mild 296.02 Bipolar I Disorder, Single Manic Episode, Moderate 296.03 Bipolar I Disorder, Single Manic Episode, Severe Without Psychotic Features 296.04 Bipolar I Disorder, Single Manic Episode, Severe With Psychotic Features 296.05 Bipolar I Disorder, Single Manic Episode, In Partial Remission 296.06 Bipolar I Disorder, Single Manic Episode, In Full Remission 296.10 Manic disorder, recurrent episode; Unspecified 296.11 Manic disorder, recurrent episode; Mild 296.12 Manic disorder, recurrent episode; Moderate 296.13 Manic disorder, recurrent episode; Severe Without Psychotic Features 296.14 Manic disorder, recurrent episode; Severe With Psychotic Features 296.15 Manic disorder, recurrent episode; In Partial Remission 296.16 Manic disorder, recurrent episode; In Full Remission 296.40 Bipolar I Disorder, Most Recent Episode Manic, Unspecified 296.41 Bipolar I Disorder, Most Recent Episode Manic, Mild 296.42 Bipolar I Disorder, Most Recent Episode Manic, Moderate 296.43 Bipolar I Disorder, Most Recent Episode Manic, Severe Without Psychotic Features 296.44 Bipolar I Disorder, Most Recent Episode Manic, Severe With Psychotic Features 296.45 Bipolar I Disorder, Most Recent Episode Manic, In Partial Remission 296.46 Bipolar I Disorder, Most Recent Episode Manic, In Full Remission 296.50 Bipolar I Disorder, Most Recent Episode Depressed, Unspecified 296.51 Bipolar I Disorder, Most Recent Episode Depressed, Mild 296.52 Bipolar I Disorder, Most Recent Episode Depressed, Moderate 296.53 Bipolar I Disorder, Most Recent Episode Depressed, Severe Without Psychotic Features 296.54 Bipolar I Disorder, Most Recent Episode Depressed, Severe With Psychotic Features 296.55 Bipolar I Disorder, Most Recent Episode Depressed, In Partial Remission 296.56 Bipolar I Disorder, Most Recent Episode Depressed, In Full Remission 296.60 Bipolar I Disorder, Most Recent Episode Mixed, Unspecified 296.61 Bipolar I Disorder, Most Recent Episode Mixed, Mild 296.62 Bipolar I Disorder, Most Recent Episode Mixed, Moderate 296.63 Bipolar I Disorder, Most Recent Episode Mixed, Severe Without Psychotic Features 296.64 Bipolar I Disorder, Most Recent Episode Mixed, Severe With Psychotic Features 296.65 Bipolar I Disorder, Most Recent Episode Mixed, In Partial Remission 296.66 Bipolar I Disorder, Most Recent Episode Mixed, In Full Remission 296.7 Bipolar I Disorder, Most Recent Episode Unspecified 296.80 Bipolar Disorder NOS 296.81 Atypical manic disorder 296.82 Atypical depressive disorder Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. 7

Depression Care Measures 2013 Direct Data Submission Measurement Specifications ICD-9 Diagnosis Code 296.89 301.0 301.1 301.10 301.11 301.12 301.13 301.2 301.20 301.21 301.22 301.3 301.4 301.5 301.50 301.51 301.59 301.6 301.7 301.8 301.81 301.82 301.83 301.84 301.89 301.9

ICD-9 Diagnosis Code Description Bipolar II Disorder Paranoid personality disorder Affective personality disorder Affective personality disorder unspecified Chronic hypomanic personality disorder Chronic depressive personality disorder Cyclothymic disorder Schizoid personality disorder Schizoid personality disorder unspecified Introverted personality Schizotypal personality disorder Explosive personality disorder Obsessive-compulsive personality disorder Histrionic personality disorder Histrionic personality disorder unspecified Chronic factitious illness with physical symptoms Other histrionic personality disorder Dependent personality disorder Antisocial personality disorder Other personality disorders Narcissistic personality disorder Avoidant personality disorder Borderline personality disorder Passive-aggressive personality Other personality disorders Unspecified personality disorder


Depression Care Measures 2013 Direct Data Submission Measurement Specifications Is the patient age 18 or older?

No

Patient not included

No


Depression Measure Logic for Patients who Are NOT Indexed

Yes

Has the patient been seen by a provider during the measurement period? Yes

PATIENT INCLUDED IN CLINIC LEVEL POPULATION COUNTS Does the patient have a diagnosis code listed in Table 1 on page 6?

No

Does the patient have a diagnosis of 311.x?

Yes

Is the diagnosis in the primary position if the patient was seen by a behavioral health provider or in any position if they were seen by a primary care provider?

No


No

Yes


PATIENT INCLUDED IN THE CLINIC LEVEL POPULATION COUNTS However, do not submit patient data for the depression measure

Yes

PATIENT INCLUDED IN CLINIC LEVEL POPULATION COUNTS

Did the patient have a PHQ-9 test completed?

No


No


Yes


Was the PHQ-9 test score above 9? Yes

PATIENT IN DENOMINATOR AND CONSIDERED AN “INDEXED” PATIENT

NOTE: Please see Pages 32-33 for the definitions of the Clinic Level Population Counts


Depression Care Measures 2013 Direct Data Submission Measurement Specifications Has the patient been seen by a provider during the measurement period?

No

NO PATIENT DATA TO SUBMIT

No

NO PATIENT DATA TO SUBMIT

Yes


Did the patient have a PHQ-9 test completed?

Depression Measure Logic for Patients who Are Indexed

Yes

SUBMIT PATIENT DATA ANSWER BOTH THE FOLLOWING QUESTIONS TO DETERMINE IF THE PATIENT MEETS NUMERATOR CRITERIA FOR REMISSION OR RESPONSE RATES

1. Was the PHQ-9 score less than 5?

Yes

No

2. Was the PHQ-9 score reduced by 50% of the patient’s indexed PHQ-9 score?

No

PATIENT REMAINS IN DENOMINATOR FOR SIX AND TWELVE MONTH RESPONSE AND REMISSION RATES

Yes

PATIENT IN NUMERATOR FOR DEPRESSION REMISSION MEASURE; PORTAL CALCULATES RATE FOR SIX AND TWELVE MONTH REMISSION RATES

PATIENT IN NUMERATOR FOR DEPRESSION RESPONSE MEASURE; PORTAL CALCULATES RATE FOR SIX AND TWELVE MONTH RESPONSE RATES

NOTE: Please see Page 32-33 for the definitions of the Clinic Level Population Counts



Data Elements and Field Specifications


Depression Care Measures 2013 Direct Data Submission Data Elements and Field Specifications Column Field Name

Notes

Excel Format Example

A

Enter a unique patient ID that will identify each patient and assigned by the clinic.

Text

Patient ID



987654

The patient ID assigned needs to identify the patient uniquely and the patient ID needs to remain constant over all data submissions in order to track outcomes at six and twelve months. You may use any field in your system that uniquely identifies the patient. If the medical record number is the only field that uniquely identifies the patient over time, it is acceptable to use this.

Blank values will create an ERROR upon submission. B

Patient Date of Birth

Enter the patient’s date of birth. Patient must be 18 or older (no upper age limit) at the start of the measurement period.

Date 05/08/1985 (mm/dd/yyyy)

It is also acceptable to use age at the time of the encounter or birth date earlier than 18 years prior to the first day of the measure period. For example, for the 02/01/2012 to 05/31/2012 measurement period, include anyone born on or prior to 02/01/1994 to ensure that the patient is at least 18 years old during that measure period. Blank values will create an ERROR upon submission. C

Clinic ID

Enter the MNCM Clinic ID for every row submitted. MNCM assigns the clinic ID at the time of registration. Clinic Use the MNCM ID listed in the portal. Do NOT use the Medical Group ID.

Text

304

Text

F

Blank values will create an ERROR upon submission. D

Patient Gender

Enter the patient’s gender: Female = F; Male = M; Unknown = U Blank values will create an ERROR upon submission. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. 12


Notes


E

Enter the patient’s five-digit zip code of primary residence at the most recent encounter on or prior to 01/31/2013.

Text

Patient Zip Code, Primary Residence



55111

If EMR query extracts a nine digit number, submit the nine digit number (the portal will remove the last four digits automatically).

Blank values and values less than five digits will create an ERROR upon submission. F

Race/Ethnicity1

G

Race/Ethnicity 2

H

Race/Ethnicity 3

I

Race/Ethnicity 4

J

Race/Ethnicity 5

K

Country of Origin Code

L

Country of Origin “Other” Description

Please refer to a separate document entitled REL Data Field Specifications and Codes 2013 for these field specifications.

M

Preferred Language Code

N

Preferred Language “Other” Description

This document can be found under the Resources tab after selecting “Race/Ethnicity/Language (REL)” section from the drop-down menu. For more information about collecting this data from patients in your clinic practice, please refer to the Handbook on the Collection of Race Ethnicity and Language Data available at www.mncm.org.



Notes


O

Enter the ten-digit NPI number of the provider who manages the patient’s care. The provider from the index contact is the provider that the patient will be attributed to.

Text

1234567891

Number

8

Provider NPI

If the provider does not have an NPI, enter the provider ID as registered in the MNCM Data Portal. Blank values will create an ERROR upon submission. P

Provider Specialty Code

Enter the specialty code of the physician (see codes below). If the provider is not a physician, enter the code that best describes the clinic’s specialty. 1 = Family Practice 2 = Internal Medicine 5 = Geriatric Medicine 8 = Psychiatry 9 = Obstetrics/ Gynecology * * PLEASE NOTE: OBGYN providers who function in a primary care role and/or treat patients with major depression are encouraged to submit data for their patients with major depression and associated PHQ-9 scores but this submission is voluntary. Contact MNCM at [email protected] if there is a provider who wishes to submit data and the code is not listed above or if you have questions. Blank values will create an ERROR upon submission.



Notes

Q

Insurance Coverage Code

R

Insurance Coverage “Other” Description Insurance Plan Member ID

S


Please refer to a separate document entitled Insurance Coverage Data Field Specifications and Codes for these field specifications. This document can be found under the Resources tab in the data portal under the “Insurance Coverage Info” section from the drop-down menu. PLEASE NOTE: This should be the patients’ most recent insurance on or prior to 01/31/2013

T

Diagnosis

Enter the diagnosis code for the visit. If a patient has multiple diagnoses, only list one.   

Text

296.32

296.2x = Major depressive disorder, single episode 296.3x = Major depressive disorder, recurrent episode 300.4 = Dysthymic disorder

Please see Table 1 on page 6 for a list of acceptable diagnosis codes. Blank values will be accepted ONLY IF the patient has been identified as meeting inclusion criteria on a previous visit. If this field is left blank and the patient HAS NOT previously meet inclusion criteria, the information will be discarded by the portal. U

Contact Date

Enter the date of visit, telephone call, e-visit or other contact that is associated with the PHQ-9 tool given to the patient. 

Once the patient has been identified as meeting the inclusion criteria of diagnosis codes and PHQ-9 greater than 9, include all subsequent contact dates and PHQ-9 scores for the patient, regardless of diagnosis, staff administering the PHQ-9 or setting in which the PHQ9 is administered within your medical group.

Blank values will create an ERROR upon submission. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. 15



Notes


V

Enter the PHQ-9 total score associated with the contact date entered in Column U.

Number

PHQ-9 Score



It is expected that once the patient has been identified as meeting the inclusion criteria, ALL subsequent PHQ-9 scores that are a part of your medical record will be included.



If no PHQ-9 was done, leave blank. You do not need to submit contact dates in which a PHQ-9 test was not done, however if your EMR system automatically pulls these visits, the portal will accept them.



Do NOT include decimals as part of the score, only submit whole scores.



Do NOT include incomplete PHQ-9 scores. In this situation, leave the score field blank. For example, a patient only answers the first five questions which total up to a score of four, submitting “4” might falsely indicate remission when this may not be the case.



Only include a score of “0” if this is the patient’s actual score (all answers are “Not at All”). DO NOT use zero to indicate a blank score



If a patient still has a high PHQ-9 (greater than nine) score 13 months or more after the index visit (activation) then the patient’s record will be marked as “re-activation” and the measurement cycle will begin again. This patient is still meeting inclusion criteria and has another chance for meeting the outcome of remission.

Blank values will create an ERROR upon submission.


13


Notes


W

If the patient has a valid reason for exclusion from the depression measures, enter the exclusion reason code. The following codes are acceptable exclusion codes. Blank values are accepted if the patient does not meet exclusion criteria.

Number

Exclusion Reason

1 = Death 3 = Hospice 4 = Permanent Resident of Nursing Home 5 = Bipolar Disorder (see Table 2 on pages 7-8) 6 = Personality Disorder (see Table 2 on pages 7-8) PLEASE NOTE: For Patient Death, Hospice and Permanent Resident of Nursing Home Exclusions: 

Do NOT exclude patients “up front” in the query process for identifying your population. Include the eligible patients as part of the submission file and enter a valid exclusion code and date. Please document how you are identifying exclusions in your denominator certification document. If an exclusion event occurs after a patient has already been submitted, a subsequent record could contain data for the “Exclusion Reason” and “Exclusion Date” fields. Having an exclusion reason and date would prevent the patient being counted in the outcome calculations. If you do not know the exact date of the event, it is acceptable to enter a date that represents the month in which it occurs like 06/01/2012 to represent June 2012.


1


Notes

W (cont.)

Exclusion Reason

For Bipolar Disorder and Personality Disorder Exclusions:

X

Exclusion Date



Excel Format Example It is acceptable to exclude patients with a bipolar or personality disorder in any position for both behavioral health and primary care providers up front. See Table 2 on pages 7-8 for a list of acceptable exclusion diagnosis codes. Medical groups can now structure their queries to exclude any patient with a secondary or primary diagnosis of bipolar or personality disorder.

Date the patient exclusion is documented. Blank values are accepted if the patient does not meet exclusion criteria.




Direct Data Submission Instructions


Depression Care Measures 2013 Direct Data Submission Direct Data Submission Instructions Summary of Changes

Best Practice Questions When entering the denominator you will now be asked to indicate if you follow best practices for Race, Ethnicity, Language and Country of Origin data collection. Please refer to Step 1 under Data File Creation and Data Submission on page 49 for more detailed instruction. Data Comparison Tool After you upload the data, you will be asked to review the preliminary rates in comparison to the last data submission cycle’s rates for this measure. Please refer to Step 4 under Data File Creation and Data Submission on page 50 for more detailed instruction.

About Direct Data Submission The goal of Direct Data Submission (DDS) is to collect data from medical groups on specific health care conditions and publically report comparable rates of health care quality at the clinic site level. All medical groups follow the same instructions for population identification and data collection. MNCM certifies methodologies prior to data collection. Then, each medical group submits data to MNCM via a secure, online data portal. As an independent auditor, MNCM validates the data for accuracy, calculates rates from the validated data, and publicly reports the data on the MNCM Web site www.mnhealthscores.org. There are benefits to medical groups for submitting data through the DDS process. First, DDS rates represent the clinic patient population. DDS also fulfills participation requirements for health plan pay-for-performance programs as well as Minnesota Bridges to Excellence. In addition, DDS results can be used by medical groups for quality improvement purposes.

Required Reporting DDS fulfills participation requirements for the Minnesota Department of Health’s Minnesota Statewide Quality Reporting and Measurement System as well as other health plan pay-for-performance programs and Minnesota Bridges to Excellence.


Depression Care Measures 2013 Direct Data Submission Direct Data Submission Instructions

DDS Participation Requirements To participate in the DDS process, medical groups must agree to: 

Follow the MNCM timeline outlined in this guide



Accept and agree to MNCM’s Site Terms of Use Agreement (electronically signed in MNCM Data Portal)



Implement the use of the PHQ-9 tool for patients with major depression or dysthymia



Submit data for all clinic sites



Submit data in required format (.csv)



Participate in the data validation processes as required by MNCM



Have results publicly reported on www.mnhealthscores.org and the annual Health Care Quality Report.

Thank you for participating in Direct Data Submission! MN Community Measurement appreciates your participation in DDS. Medical groups’ efforts to submit data via DDS allows MN Community Measurement to report comparable health care quality rates in Minnesota and communities that border Minnesota.



Confidentiality and HIPAA for Direct Data Submission Our legal firm, Lindquist & Vennum P.L.L.P., has assured us that direct data submission fits within the scope of lawful compliance with HIPAA and MN statute as long as we have a signed Business Associate Agreement (BAA) with the medical group. This document can be electronically signed on the MNCM Data Portal, or MNCM would be open to signing a medical group’s standard BAA document version. The BAA is signed annually and remains in effect for all direct data submissions for the year.

Health Insurance Portability and Accountability Act (HIPAA) Law: 

This activity is considered within the scope of “health care operations” associated with the medical group quality improvement efforts.



The federal HIPAA law specifically allows release of individually identifiable health information - without the consent or authorization of the individual - for treatment, payment and health care operations of, or for, the provider.

Minnesota Statute: 

The primary governing Minnesota statute is MN Stat. Section 144.335.



Subd. 3a. entitled "Patient consent to release of records; liability" states: (a) A provider, or a person who receives health records from a provider, may not release a patient's health records to a person without a signed and dated consent from the patient or the patient's legally authorized representative authorizing the release, unless the release is specifically authorized by law.



However, the statute does not restrict release (without patient authorization) to only those circumstances authorized by state law.



Legal opinion assures us that it is reasonable to conclude that the HIPAA privacy regulation does specifically address authorization for release of such information. The appropriate method for a covered entity to allow such release and to verify the release is for a certain, narrow purpose, is either via a data confidentiality agreement or, if the auditor or other entity to whom the information is released will be maintaining any individually identifiable health information, a business associate agreement.

American Recovery and Reinvestment Act of 2009: 

MNCM ensures HIPAA compliance with the new ARRA provisions.



Overview of the Process and Timelines Process Step Registration Medical group registers clinics and providers on the MNCM Data Portal and electronically signs the Site Terms of Use Agreement and Business Associate Agreement.

Helpful Dates to Remember  Registration begins December 12, 2012  Deadline: February 8, 2013

Resource: Download Clinic and Provider Registrations Instructions from the Resource Tab on the MNCM Data Portal https://data.mncm.org/login or www.mncm.org. Denominator Certification Medical group submits a denominator document outlining the method for identifying the patient population to the MNCM Data Portal. MNCM reviews and approves the denominator. MNCM must approve your denominator before you begin pulling your data. Please plan accordingly.

 Submit denominator document in January 2013 or early February 2013  MNCM responds within 2-3 business days after receiving the denominator document

Resources: Download Depression Care Measures 2013 Denominator Template from Resource Tab on the MNCM Data Portal Data Collection and Submission Medical group collects data and maintains a “crosswalk” of the patient list for future patient identification. Data collection begins after the billing cycle is completed for the measurement period. Medical group prepares file (.csv format) to submit to MNCM via the MNCM Data Portal.

 MNCM Data Portal opens: February 4, 2013  MNCM Data Portal closes: February 28, 2013

Resources: Download Data Collection Guide Depression Care Measures 2013 and Data Collection Spreadsheet Template from Resource Tab on the MNCM Data Portal Data Validation

Resources: Crosswalk patient list, Data collection forms/spreadsheet with notes, Staff participation

A MNCM auditor will contact the medical group to schedule the validation audit after the data file is successfully uploaded onto the MNCM Data Portal.

Data Results

May 2013

MNCM auditor conducts audits to validate that the submitted data matches the source data in the patient medical record.

After the successful submission and validation of the clinical data, MNCM will post the results on www.mnhealthscores.org.


Depression Care Measures 2013 Direct Data Submission Direct Data Submission Instructions Timeline for Direct Data Submission: Depression Measure There are two different timeline options for submitting data for the depression measure. Submission for the depression measure follows a file structure consisting of three separate measurement periods. The defined dates are to allow a +/- 30 day window to obtain a PHQ-9 score within six months. Both of these timeline options fulfill the requirements of the Minnesota Statewide Quality and Reporting Measurement System. Measurement Period: Refers to the four-month period that is associated with data Files 1-3. See below for specific measurement period dates of service. Measurement Year: Refers to the twelve-month period that encompasses all measurement periods. The measurement year for the Depression Measure is 02/01/2012 to 01/31/2013. Timeline 1: You will submit three separate files one time after the end of the measurement year in sequential order to the MNCM Data Portal in February 2013. Your data collection can occur on one master spreadsheet but the files will need to be separated by date of service before submission. Timeline 1: Groups Submitting in February 2013 (One time submission) File

Measurement Period Dates of Service

File #1

02/01/2012

05/31/2012

File #2

06/01/2012

09/30/2012

File #3

10/01/2012

01/31/2013

Portal Opens for Data Submission

Portal Data Submission Deadline

02/04/2013

02/28/2013

Timeline 2: You will submit three separate files to the MNCM Data Portal, one file after the end of each of the measurement periods. You will submit the first file in June 2012, the second file in October 2012 and the third file in February 2013. In order to submit throughout the year, you must adhere to these timelines. If you miss the 06/30/2012 deadline, you must then submit using Timeline 1. Timeline 2: Groups Submitting Three times during Measurement Year (Multiple submissions) File

Measurement Period Dates of Service

Portal Opens for Data Submission

Portal Data Submission Deadline

File #1

02/01/2012

05/31/2012

06/04/2012

06/29/2012

File #2

06/01/2012

09/30/2012

10/08/2012

10/31/2012

File #3

10/01/2012

01/31/2013

02/04/2013

02/28/2013


Depression Care Measures 2013 Direct Data Submission Direct Data Submission Instructions Timeline for Public Reporting of Depression Measure rates on MN HealthScores Since the reporting functionality needs to account for the six and twelve-months (+/- 30 days) worth of history needed to calculate rates for each patient, there is a lag time of when the six and twelve month rates are able to be calculated. Below is the anticipated timeline for reported Depression Measure rates on the MNHealthScores website. Depression Measure

Date Ranges

Six Month Remission

Index Contact Dates +

Utilization of PHQ-9 Tool Number of patients with major depression or dysthymia seen during the measurement period (4 months) who are administered at least one PHQ-9 during that four-month measurement period. Twelve Month Remission

Anticipated Reporting on MN HealthScores

07/01/2008 to 06/30/2009

May 2010

07/01/2009 to 06/30/2010

May 2011

07/01/2010 to 06/30/2011

May 2012

07/01/2011 to 06/30/2012

May 2013

Dates of Service 10/01/2011 to 01/31/2012

May 2012

10/01/2012 to 01/31/2013

May 2013

10/01/2013 to 01/31/2014

May 2014

Index Contact Dates 01/01/2009 to 12/31/2009

June 2011

01/01/2010 to 12/31/2010

June 2012

01/01/2011 to 12/31/2011

June 2013

01/01/2012 to 12/31/2012

June 2014

+ Index Contact Date is the date in which the patient meets inclusion criteria (diagnosis of major depression or dysthymia and PHQ-9 greater than 9) and serves as the anchor date from which the measurement by date occurs for six and twelve month remission.



Resources to Help You Get Started To identify your population, collect data, and get started in the data submission process, MN Community Measurement offers a selection of resources and tools.

To access the resources and tools for Depression measure, log in to the data portal at: https://data.mncm.org and click on the RESOURCES tab.

Select Depression RESOURCES from the drop-down menu.

The Depression RESOURCES screen contains Frequently Asked Questions, Depression Patient Assessment Tools and Depression resources. The documents you will need to download include: 

Depression Care Measures Data Collection Guide 2013



Depression Care Measures 2013 Excel Template



Depression Care Measures 2013 Denominator Template



Depression Care Measures 2013 Data Collection Form (most useful for medical groups and clinics using paper records)



Step 1: Registration and Data Submission Preparations Your medical group/clinic should have previously registered with MNCM. Registration must be completed once annually. Please refer to separate registration instructions for this process. A downloadable instructional guide will be available on the MNCM Data Portal. PLEASE NOTE: If your medical group added or closed clinics after registering, please contact MNCM to update your registration and clinic information. Other data submission preparations: 



Save the MNCM Web sites in your “Favorites” internet folder for future reference. o

MNCM Data Portal: https://data.mncm.org/login

o

MNCM Web Site: www.mncm.org

o

MN HealthScores: www.mnhealthscores.org

Create a folder in your network drive dedicated to all data submission documents. o

Save all spreadsheets, forms and data submission materials in the dedicated folder.



Name versions of documents clearly, so you are using the most recent files.



Log in to the MNCM Data Portal at https://data.mncm.org/login. In the Resources tab of the data portal, you are able to access the following items: o

Direct Data Submission Resources. Download the following 

Depression Care Measures 2013 Direct Data Submission Guide



Depression Care Measures 2013 Denominator Certification Form



Depression Care Measures 2013 Data Collection Form



Depression Care Measures 2013 Spreadsheet Template



Step 2: Identifying the Patient Population (Denominator) Denominator Definition: The denominator is the bottom number in a fraction. In this step, the total number of patients who are eligible for the measure are identified using a standard set of criteria. Please review the “Denominator” section noted in the Measure Specifications in this guide for the detailed criteria used to identify eligible patients for the denominator.

Certification of the Patient Population (Denominator Certification) To help medical groups achieve accuracy and/or inadvertently pulling the wrong patient population for the measure, MNCM will complete an upfront review of each medical group’s source code or methodology that is used to produce the patient population (denominator) to help identify potential errors. The denominator certification process is intended to help identify potential issues prior to data submission. However, the responsibility to submit an accurate denominator rests with the medical group. Please contact [email protected] with any specific questions. PLEASE NOTE: Denominator certification may also include a comprehensive review by MNCM of the process steps used to identify the denominator, including the final list of patients. Please save all original queries, documents, spreadsheets and process steps that are used to identify the patient population. MNCM may ask to review this information.

Denominator Template Form This template is provided to ensure all medical groups are using the same set of criteria to identify patients for the denominator. Medical groups are asked to complete this form and submit it to the MNCM Data Portal. PLEASE NOTE: The denominator form asks for source code or “screen shots” which are helpful in MNCM’s review of the denominator. 1. Login to the MNCM Data Portal (https://mncm.data.org) 2. Go to the Resources tab > Depression Resources > download the Depression Care Measures 2013 Denominator Template form 3. Complete the form and save the form on your network directory. 4. Login to the MNCM Data Portal and click on Denominator Certification under the Depression Measure measurement period for which you are submitting data. Follow the instructions to upload the form to the data portal. 5. MNCM will review the method and respond within 2-3 business days. MNCM will either (1) contact the medical group if more clarification is needed, in which case the medical group will need to make the necessary revisions and re-upload the form, or (2) approve and certify the method in the MNCM Data Portal; an automatic e-mail will notify the medical group that the method is certified. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. 28

Depression Care Measures 2013 Direct Data Submission Direct Data Submission Instructions Details for the Denominator Methodology The following elements are included on the denominator template form. Medical groups will need to indicate on the form how they will identify each element for MNCM: 

Date of birth range



ICD-9-CM codes included in query

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Visit date range that ensures correct dates of service were queried

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Board certified specialties offered by the medical group that ensures the appropriate specialties for each measure were included

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Whether exclusions will be taken and how exclusions will be handled o

EMR groups can list which accepted exclusions will be filtered through the query process

o

Medical groups that will manually abstract data can describe that exclusions will be identified and documented during record review

Identifying patients The following components must be used to identify patients: 1. Eligible Providers and Encounter Types Patients who have visits with provider who practice in the following specialties are included in the depression measurement. Eligible providers include primary care and behavioral health providers. The following is a comprehensive list of billable providers who practice independently and diagnosis and treat patients with major depression or dysthymia: Primary Care

Behavioral Health

Family Practice

Psychiatrist

Internal Medicine

Physician Assistant

Geriatric Medicine

Nurse Practitioner

Obstetrics/ Gynecology *

Clinical Nurse Specialist

Physician Assistant

Psychologist (LP)

Nurse Practitioner

Clinical Social Worker (LICSW) Counselor (LPCC) Marriage and Family Therapist (LMFT)

*OBGYN providers who function in a primary care role and/or treat patients with major depression are encouraged to submit data for their patients with major depression and associated PHQ-9 scores but this is voluntary. Contact MNCM at [email protected] if you have questions.


Depression Care Measures 2013 Direct Data Submission Direct Data Submission Instructions 2. Eligible Patients If a patient IS NOT AN INDEXED patient: In order to be eligible for this measure, patients must initially meet the following criteria: 1. Depression Diagnosis Patients must have one of the following diagnoses (the diagnosis can be in any position for primary care providers and must be in the primary position for behavioral health providers): 

296.2.x Major depressive disorder, single episode



296.3x Major depressive disorder, recurrent episode



300.4 Dysthymic disorder

2. PHQ-9 Administration Patients must have been administered a PHQ-9 test at a face-to-face visit with an eligible provider of which one of the above diagnoses is associated with the visit AND scored above a 9. Once the two above criterions are met, the patient is considered an “indexed” patient. The “indexed” visit is the visit in which the patient scored above nine on the PHQ-9 test at a face-to-face visit with an eligible provider AND had an eligible diagnosis associated with that particular visit. If a patient IS AN INDEXED patient: Once the patient has been indexed, the patient must be tracked and all subsequent visits during which a PHQ-9 test is administered must be included in the patient file. Include these visits regardless of diagnosis, staff administering the PHQ-9 or setting in which the PHQ-9 is administered within your medical group. Other acceptable encounter/ visit types for subsequent contact with an indexed patient include: 

Office Visit



Telephone Encounter



E-Visit



Any other contact with the patient in which a PHQ-9 is administered

Patient attribution: A patient is attributed to the clinic site and provider of the indexed visit (diagnosis codes for major depression or dysthymia and a PHQ-9 score greater than nine). The portal then matches all subsequent contact dates and PHQ-9 scores to this patient within the medical group regardless of the clinic location of the contact. Note for Primary Care Clinics: If a medical group assigns a primary care provider for each patient, it is acceptable to use that provider ID in this field. If a group does not assign a primary care provider, then use the provider ID of the provider who cared for the patient at the visit. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. 30

Depression Care Measures 2013 Direct Data Submission Direct Data Submission Instructions System Query: Helpful data elements that can be included in the system query When querying your system (either EMR or billing system) to identify patients with depression who could be included in either your counts or as part of the file submission, it is helpful to pull as much of the needed demographic information as possible at the same time.

Keep a “Crosswalk”: It is very important to keep a “crosswalk” between the unique identifier and the patient’s name and DOB, so that records can be located by clinic staff at the time of validation by MNCM.



Patient ID number (If you will substitute this number with a unique number, keep a “crosswalk” of this information for the validation audit. PLEASE NOTE: The Patient ID number must be maintained for patients across all measurement periods. Do NOT submit Social Security Numbers.)






Clinic or facility (This information must be substituted with the corresponding MNCM-assigned Clinic ID as listed in the portal)

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Provider name and NPI

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Provider type/specialty code (This information must be substituted in the data file with the MNCMassigned specialty code.)

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Insurance payer (This information must be substituted in the data file with the MNCM-assigned insurance code. This should be the patients’ most recent insurance on or prior to 01/31/2013.)



Insurance member ID (This information must be formatted at TEXT in the Excel file so that IDs with numbers and letters or leading zeros maintain their format. Do no submit Social Security Numbers.)



Gender



Zip Code



Race/ Ethnicity (Please refer to the REL Data Field Specifications and Codes document references in the field specification section for the corresponding codes.)

If a medical group opened or acquired a new clinic in the last year, the new clinic must register and submit data with the medical group. If the new clinic uses a different practice management system, billing system or EMR, they would identify patients and collect the data separately from the other clinics in the medical group, but would include their data in the same file that the medical group submits to MNCM (the identifier is the Clinic ID). For medical groups that implemented a new practice management system or EMR in the last two years: Please consider how to generate the patient population using both systems. Two queries or patient lists may be necessary. The lists should then be combined and a common identifier(s) selected to de-duplicate the list. Please contact [email protected] with any questions.



Clinic Level Population Counts You will provide clinic level population counts as well as patient level data for patients that meet inclusion criteria for the measure. These population counts are important and contribute to the measurement calculations. IF YOUR CLINIC DOES NOT USE THE PHQ-9 TEST, YOU STILL NEED TO SUBMIT CLINIC LEVEL POPULATION COUNTS. You will only be entering in counts for this population – total numbers. These numbers are used to calculate general clinic level depression care rates for your clinic (See Appendix C for more information). In addition to creating a file of all your patients with depression and their PHQ-9 scores that meet the inclusion criteria for the measure (see next section), you will be asked to provide some summary counts in the data portal. Prior to file upload of the denominator file, medical groups enter the counts of the following during the measurement period. These counts are entered directly into the portal by clinic site. These counts that are calculated will not necessarily match the number of patients that meet the inclusion criteria (see next step) as those are patients that have both a diagnosis of major depression/dysthymia AND a PHQ-9 score of greater than 9. These are more general clinic level population counts.

Purpose To provide information about the population of patients cared for at each clinic site and to understand the processes related to diagnosis, monitoring and treatment of depression.   

The incidence of major depression/ dysthymia in the clinic’s adult population The use or overuse of the non-specific ICD-9 code for depression (311) The utilization of the PHQ-9 tool for patients with diagnosed depression/ dysthymia

All counts pertain to the current measurement period. For example, if the measurement period is 02/01/2012 to 05/31/2012, you would count the number of patients in each category during that measurement period. All are counts of unique patients, not the number of visits.

Clinic Level Population Count 1: Total Adult Patients The total number of unique adult patients (ages 18+) seen in your clinic for any reason with a contact with a billable provider during the measurement period.


Depression Care Measures 2013 Direct Data Submission Direct Data Submission Instructions Clinic Level Population Count 2: Total Adult Patients with Depression Diagnosis (296.2x, 296.3x or 300.4) These ICD-9 codes define major depression and dysthymia and would be a subset of your total adult patients. It does not matter if this is a new diagnosis or if the patient is returning for a follow-up visit. If they have these codes during the measurement period, include them in the count. If the patient has an exclusion ICD-9 diagnosis codes, do NOT include them in this count. The total number of adult patients with a contact with a billable provider who have at least one contact in the measurement period with the following ICD-9 codes:  296.2x Major depressive disorder, single episode  296.3x Major depressive disorder, recurrent episode  300.4 Dysthymic disorder If the provider is primary care, the ICD-9 codes can be in any position. If the provider is behavioral health, the ICD-9 codes need to be in the primary position only. This excludes patients with other psychiatric diagnoses with a secondary component of depression. IF YOUR CLINIC DID NOT SEE ANY PATIENTS WITH A DIAGNOSIS OF MAJOR DEPRESSION OR DYSTHYMIA: You will enter a “0” for this count. YOU MUST ALSO CHECK “No Depression Patients Seen this Period.”

Clinic Level Population Count 3: Total Adult Patients with Depression NOS (311) code This would be another subset of your adult population. The total number of adult patients with a contact with a billable provider with a 311 code (Depression NOS not elsewhere classified). Because one of the goals of measuring this population is accurate diagnosis (and subsequently coding), please only include in this count patients who have a 311 code and not the major depression/ dysthymia codes of (296.2, 296.3 or 300.4). One way you could structure your query would be to search for ICD-9 code = 311 and is not equal to 296.2, 296.3 or 300.4. If the patient has an exclusion ICD-9 diagnosis codes, do NOT include them in this count.

Clinic Level Population Count 4: Total Adult Patients with a Completed PHQ-9 AND diagnosis of Major Depression or Dysthymia (296.2x, 296.3x or 300.4) This is a subset of the patients ages 18+ with the major depression/ dysthymia diagnosis codes of (296.2, 296.3 or 300.4) Count the number of these patients during the measurement period who also have a PHQ-9 test done during the measurement period. If a patient has an exclusion ICD-9 diagnosis code, do NOT include them in this count. PLEASE NOTE: It is acceptable to “count” a patient has having a PHQ-9 administered if the patient only partially completed the PHQ-9 tool, but do NOT send partial scores as part of your denominator file. IF YOUR CLINIC DOES NOT USE THE PHQ-9 TEST: You will enter a “0” for this count. Do NOT check “No Depression Patients Seen this Period” unless your clinic truly had no patients with a depression diagnosis seen during this measurement period. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. 33


Patient Level Data Please see the Data Elements and Field Specifications section to review data you will submit for indexed (previous and new) patients.

Allowable Exclusion Reasons for Patients with Depression:     

Patient death Hospice Permanent Resident of Nursing Home Bipolar Disorder (see Table 2 on pages 7-8) Personality Disorder (see Table 2 on pages 7-8)

For Patient Death, Hospice and Permanent Resident of Nursing Home Exclusions Do NOT exclude patients “up front” in the query process for identifying your population. Include the eligible patients as part of the submission file and enter a valid exclusion code and date. Please document how you are identifying exclusions in your denominator certification document. If an exclusion event occurs after a patient has already been submitted, a subsequent record could contain data for the “Exclusion Reason” and “Exclusion Date” fields. Having an exclusion reason and date would prevent the patient being counted in the outcome calculations. If you do not know the exact date of the event, it is acceptable to enter a date that represents the month in which it occurs like 06/01/2012 to represent June 2012. For Bipolar Disorder and Personality Disorder Exclusions It is acceptable to exclude patients with a bipolar or personality disorder (listed in Table 2 on pages 7-8) in any position for both behavioral health and primary care providers upfront. Medical groups can now structure their queries to exclude any patient with a secondary or primary diagnosis of bipolar or personality disorder. For patients that have already been submitted to the data portal and now have bipolar or personality disorder as a diagnosis (primary or not), please submit a record for each patient that includes an exclusion code and reason (Code 5 for bipolar and Code 6 for personality disorder) in the first data file for 2012 dates of service (02/01/2012 to 05/31/2012 Dates of Service). It is acceptable to create a fake encounter with the date of 02/01/2012. This will exclude the patient from the measure. Moving forward, any new patient who has bipolar or personality disorder can be excluded upfront through queries and does not need to be submitted in the data file with a visit and exclusion code and date. PLEASE NOTE: These exclusions may be taken by the medical group if the information is available, however, it is optional. If the information is unknown to the clinic, the patient is to be included.


Depression Care Measures 2013 Direct Data Submission Direct Data Submission Instructions Eligible Visits: Evaluation & Management CPT Codes (optional) The following list of codes may be helpful in determining what types of visits to include for identifying the patient population (denominator). E & M codes do not need to be used when querying a practice management system to determine visit counts; however, they have been included here to help further define what is meant by a “face-to-face” visit with a provider. Please refer to a CPT coding manual for more details. Description Individual Psychotherapy E & M Codes Preventive Codes Office Consultation Individual Counseling Group Counseling Other Preventive Medicine Services Other Outpatient Encounters Unlisted E & M Codes

CPT Codes 90804-90815 99201-99205; 99211-99215 99385-99387; 99395-99397, 99383-99386, 99393-99396 99241-99245 99401-99404 99411-99412 99420; 99429 98960-98962; 99078; 99217- 99220; 99341-99345; 99347-99350; 99499

About Total Population Submission This measure requires total population submission. When a medical group or clinic submits “total population”, they are submitting data for all of the eligible deliveries during the time period. The denominator should be comprised of all (or the total) number of eligible deliveries performed during the measurement period. Total population for this measure means all the primary deliveries that your providers perform for all patients within the measurement period (as opposed to pulling a sample of only some deliveries). The criterion in the denominator section of the Measure Specifications on page 5 define the eligible population and provides details on who should be identified/included in the denominator.



Step 3: Data Collection It is important to understand a few things about how the portal functions for this unique data set that is longitudinal and involves multiple submissions to capture a patient’s experience over a twelve month (+/- 30 days) measurement period. Records are also submitted at a patient visit or contact level; not at the level of an individual patient like diabetes or vascular direct data submissions. It is expected to have several records for one patient, one record for each PHQ-9 score administered. Important note for those submitting all three files in February 2013 at one time: You may use one spreadsheet to collect all of your data for 2012-2013 dates of service. However, prior to uploading your data you will need to sort your file by contact date and then create three separate files for the three measurement periods. Medical groups can collect clinical data from medical records by either: 1) extracting the data from an electronic medical record through a data query; or 2) abstracting the data from the medical record (paper record or EMR). Data collection occurs after: 1. The clinic’s billing and medical record updates are complete for the measurement period; 2. The denominator method is certified by MNCM; and 3. The patient population is pulled, and if applicable, a sample is selected according to the measure specifications and sampling instructions.

Tools for Data Collection and Data Entry Data Collection Form A data collection form was created for medical groups that manually collect data from an EMR or paper record. The necessary data elements are on the form. These forms can also be used to note where certain data elements were found in the medical record. Data collected on these forms must also be entered into the Excel file mentioned below. Please download these forms from the MNCM Data Portal, Resources tab, select Depression Resources from the drop-down menu. Excel Template The Excel template was created to ensure all necessary data elements are collected for DDS. This file contains all of the necessary fields and the correct column formatting according to the measure specifications. Please download the Depression Care Measures 2013 Excel template from the MNCM Data Portal, Resource tab, select Depression Resources from the drop-down menu.


Depression Care Measures 2013 Direct Data Submission Direct Data Submission Instructions Field Formatting in the Excel File: Prior to entering data in the Excel file it is important that the field formats follow the measure specifications in this guide. Pay special attention to field formatting (e.g., dates look like dates, etc.). THE EXCEL TEMPLATE PROVIDED HAS THE CORRECT FORMATTING. Do NOT use “General” formatting in Excel. The Excel template provided on the MNCM Data Portal will provide the correct formatting. Pay particular attention to the formatting of the insurance member IDs. This field must be formatted as “Text” for IDs that contain numbers and letters or leading zeros.

Using Multiple Data Collectors | Inter-Rater Reliability (IRR) Ideally, one data collector or data collection process is preferred because it ensures that the data is collected in one consistent way. If, however, more than one person will abstract data, we recommend conducting several sample audits with all abstractors for training purposes to improve IRR. Internal training could include a review of the guide and data collection form, and instructions for locating information in the clinic’s medical record. Also, refer to data collection errors made in previous submissions, make plans to improve the data collection process, and perform quality checks on the data. This ensures that the measurement specifications are interpreted consistently and that the data is collected in a uniform way.

Key Points for File Creation 





 

File submission reflects visit or contact level information; one row for each contact. The PHQ-9 can be administered by means other than an office visit, like a telephone call, and that is why we refer to the date field as a contact date. Once a patient has been indexed (i.e., identified as meeting the inclusion criteria), then all the subsequent visits/ contacts PHQ-9 scores are to be submitted, regardless of who administers the tool or diagnosis codes associated with susequent visits. All PHQ-9 scores are expected to be submitted. If a patent was contacted/ administered the PHQ-9 tool three times during the measurement period, there should be three records for this patient in the submission file. Not all subsequent contact records will have all the field information present (like diagnosis code or insurance information) and this is okay. It is important to only submit records with dates of service during the measurement period. Dates of service outside of the measurement period will cause file errors.


Depression Care Measures 2013 Direct Data Submission Direct Data Submission Instructions Portal Functionality 

In order for the programming to correctly evaluate each patient record, the file must be sorted first by PatientID and then by Contact Date with the contact dates in ascending or oldest to newest order. (05/12/2012 is an “older date” as compared to 02/01/2012 a “newer date”) This allows the portal program to evaluate each patient and incoming visit record correctly. Records that are out of sort order will not have the index and follow-up visits assigned appropriately and will not pass validation audit.



The portal is structured to look at each incoming patient record according to Medical Group ID and PatientID. The portal determines if 1) this patient is already in the portal (i.e., an indexed patient) and then will add the subsequent visits, or 2) if not already in the portal will flag as a new patient with a new index contact date.



The index visit needs to contain: o

o o o o

Diagnosis code of any of the following  296.2.x Major depressive disorder, single episode  296.3x Major depressive disorder, recurrent episode  300.4 Dysthymic disorder Provider Insurance information (Insurance Coverage Code, Health Plan/ Insurance plan Member ID) Demographic Information: (Zip, Gender, Race/Ethnicity, Language, Country of Origin) PHQ-9 score above 9



For patients who HAVE NOT BEEN indexed: If a patient visit record is submitted to the portal with the correct diagnosis codes but a low PHQ-9 score, this record will be rejected and the portal will keep searching until a visit with diagnosis codes and PHQ-9 greater than nine occurs. Likewise, if a visit record is submitted with a high PHQ-9 score but no associated diagnosis codes, the record will be rejected.



For patients who HAVE BEEN indexed: All subsequent visits are allowed to match up to that patient. This is to allow for the various settings in which a PHQ-9 can be administered (phone, e-visit or other type of visit) for which there may not be a diagnosis code or insurance information



If the patient does not yet have an index visit and other diagnosis codes are submitted, the records containing the other diagnosis will cause an error on file submission and will need to be removed.



The index visit record will contain the information that is stored for each patient. This record contains the clinic ID, the provider ID, gender, zip code, diagnosis code and insurance coverage information. The clinic site and the provider ID that are a part of the indexed visit is where the patient will be attributed to. The insurance coverage will be updated if it changes, but the rest of this record will remain the same.



A patient’s measurement period will end 13 months from the activation date; this allows for the +30 days to obtain subsequent PHQ-9 scores. If, after this point a patient does meet the inclusion criteria again by having a PHQ-9 score above nine; a new index/ re-activation record will be created and measurement will “start over” for his patient. In these situations, the patient is still meeting criteria for inclusion. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. 38

Depression Care Measures 2013 Direct Data Submission Direct Data Submission Instructions Example of a Data File PLEASE NOTE: 1.The data is completely fake data (no PHI) 2. Each color is a separate patient 3. Gender, Zip and Race fields not displayed due to space 4. Note that the file is sorted by patient ID and then contact date (oldest to newest)

Notes about the PHQ-9 Test PLEASE NOTE: If you have not already implemented the PHQ-9 assessment tool in your clinic, you need to start in order to participate in these measures, which are based on serial PHQ-9 assessments, and resulting scores. If you need to obtain a copy of the PHQ-9 tool, please access www.phqscreeners.com or you can download a copy from the data portal in the Resources section. Please include the following copy right information on all PHQ-9 assessment tools utilized by clinicians. Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.

Notes about the PHQ-9 Scores 

Once the patient has been identified as meeting the inclusion criteria of diagnosis codes and PHQ-9 greater than nine, include all subsequent contact dates and PHQ-9 scores for the patient, regardless of diagnosis or setting in which the PHQ-9 is administered within your medical group. Once the patient has been identified as meeting the inclusion criteria, then all subsequent PHQ-9 scores that are a part of your medical record are to be included.



If no PHQ-9 was done, leave blank. You do not need to submit contact dates in which a PHQ-9 test was not done, however if your EMR system pulls these visits without a PHQ-9 score automatically, the portal will accept the data, but will not use it in the rate calculation. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. 39

Depression Care Measures 2013 Direct Data Submission Direct Data Submission Instructions 

Do NOT include decimals as part of the score, only submit whole scores.



Do NOT include incomplete PHQ-9 scores, in this situation leave the score field blank. For example, a patient only answers the first five questions which total up to a score of four, submitting a four might falsely indicate remission when this may not be the case.



Only include a score of “0” zero if this is the patient’s actual score (all answers are “Not at All”), do NOT use zero to indicate a blank score.

Locating Data Elements in the Patient Record The primary source of data is the clinic’s documentation in the medical record (e.g., flow sheets, progress notes, lab reports, etc.). Data collectors may also choose to review the outside correspondence in the clinic’s medical record that documents more recent data within the measurement period, but this is optional. If data is used from outside correspondence, please document this for the validation audit. Below are tips for locating data in the patient record. Please follow the measure Data Collection specifications for data collection. Tips: As long as you are including all your patients with major depression (ICD-9 codes 296.2, 296.3 or 300.4), there are several different ways that the data collection process can be achieved: 

Extract information from your EMR by query.



Combination of extracting info from EMR and chart abstraction (for example when PHQ-9 tools are scanned into the system and scores need to be abstracted). Recommend moving towards an integrated PHQ-9 tool within your EMR so that scores can be extracted by query.



Registry populated with patients with depression and their visits.



Download as much information as can be attained from a billing system into Excel and then abstract remaining data elements.

 When manually collecting data using an EMR, highlight the row, column or cell that contains the data needed. This reduces the chance of looking at the wrong row, column or cell.  Watch for TYPOS when entering data (number transpositions, etc.).

Tracking Where Data is Located in the Patient Record It is important to keep track of where data is located in the patient record. For example, if data is used from an outside specialist or provider note (that is within the primary clinic’s record), document the source on the data collection form or Excel spreadsheet. If you are collecting data directly in the Excel spreadsheet, create a “NOTES” column and enter the data source details in this column. After you have completed data collection, SAVE A COPY of the Excel file and remove the “NOTES” column in the file that will be used for submitting to MNCM. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. 40


Patient Registries You can use the data submission template as a registry, but make sure you only send us what we need and in the original CSV format when downloaded from the portal. If changes are made to the spreadsheet, it will not upload correctly into the MNCM portal. If you are using a registry for patient identification, you need to insure that you are including all eligible patients. For clinics with paper charts, keeping a registry is the best possible temporary solution for data collection and patient tracking. During the validation audit, the MNCM auditor will review the patient record for validation and not the patient registry. If a clinic uses data from a patient registry, the auditor may find information (PHQ-9 scores) in the medical record that was not included in the submission file and this would be counted as a validation error.



Step 4: Data Quality Checks MNCM recommends completing several internal quality checks of the data before submitting the data. Performing quality checks ensures that the data is accurate and able to be validated by a MNCM auditor. If corrections are needed, make these in the Excel file. Excel’s AutoFilter Use the Filter function in Excel to look for incorrect or missing data: 

Click inside any data cell and activate the AutoFilter by doing the following: o

In Excel 2003, click the Data menu, point to Filter, and then click AutoFilter.

o

In Excel 2007 and Excel 2010, click the Data tab and in the Sort & Filter area click Filter.



The AutoFilter arrows now appear to the right of each column heading.



Click on the drop-down boxes of any column and scan for incorrect, “out-of-range” or missing data (e.g., PHQ-9 score greater than 27 or with decimals, contact dates within the measurement period).



To display all data again, click on the same drop-down box and select (All).



Remove the Filter option by doing the following: o

In Excel 2003, click Data, Filter, and AutoFilter again

o

In Excel 2007 and Excel 2010, click the Filter option again in the Sort & Filter area

Example Quality Check: Verify correct PHQ-9 scores are entered. Filter the PHQ-9 score and ensure there are no scores over 27 (the top score for PHQ-9 tests) or any scores that contain decimal points. Make changes in the Excel file if necessary. Internal Audit of Clinical Data: Before submitting the data file, you may wish to review a random sample of records (8-10) to see if the data matches what was collected from the patient record. If errors are found, make the corrections in the Excel file, however also consider if the errors were isolated cases or indicative of a larger data collection problem. (Examples of a larger data collection problem: There are no patients with PHQ-9 scores, and you are certain that PHQ-9 scores were administered.) Important Quality Checks (Excel File) It is important to complete the following quality checks of the file before submitting data to MNCM. Completing these checks can help avoid delays in the file submission and ensure that you have the most accurate data. Make any changes/additions in the Excel file before submitting data to MNCM.


Depression Care Measures 2013 Direct Data Submission Direct Data Submission Instructions Column Field Name

Quality Check

A

Verify that each cell has data. Blank values will create an ERROR upon submission.

Patient ID

Verify that patients were not duplicated: Use the Excel pivot table to do counts by patient ID (or patient insurance member ID if the patient ID is de-identified). If a duplicate is found, determine which provider/clinic the patient is attributed to and delete the other record. Keep in mind that if you are submitting a sample, you will need to replace the deleted record with the next sampled patient. B

C


Set the filter, view this field, and verify no dates of births are after 02/01/1994.

Clinic ID

Verify that all clinic IDs match the “MNCM ID” that the portal lists. Do NOT use the Medical Group ID.


Verify that each cell has data. Blank values will create an ERROR upon submission. D

Patient Gender

Verify that each cell has data. Blank values will create an ERROR upon submission. Verify that each cell is one of the accepted codes.

E

Patient Zip Code, Primary Residence

Verify that each cell has data. Blank values and values less than five digits will create an ERROR upon submission. Verify that the zip code at least five digits long. If you submit a 9-digit number, the portal will remove the last four digits automatically.

F-J

K

L

M

Race/Ethnicity Codes

Blank cells (where no data is available) are acceptable.

Country of Origin Code

Verify that accepted codes are used.

Country of Origin “Other” Description

Verify that this field is populated if “999” (other) was entered in the previous cell.

Preferred Language Code

Verify that accepted codes are used.

Verify accepted codes are used.






Quality Check

N

Preferred Language “Other” Description

Verify that this field is populated if “99” (other) was entered in the previous cell.

O

Provider NPI

Verify that each cell has a number that is 10-digits long. Blank values and values less than ten digits will create an ERROR upon submission.

P

Provider Specialty Code



Verify that each cell is one of the accepted codes. Q

Insurance Coverage Code

Verify that each cell has data. Blank values will create an ERROR upon submission. Verify that each cell is one of the accepted codes. Set the filter and view only the 99 codes: Verify that insurance names are also entered in the next field (“Other” Description). Verify that any of the entries in the “Other” Description field do not already have an available code. If there is an available code, change the code to the corresponding insurance payer. (e.g., If the description of Aetna Medicare Advantage was entered, the insurance code should be changed to 18 for Aetna.)

R

S

T

Insurance Coverage “Other” Description

Verify that this field is populated if the previous cell was entered 99 (other).

Insurance Plan Member ID

Verify that this cell has the appropriate member ID if the patient has insurance.

Diagnosis

Verify that this field is populated if data is available.


Do NOT enter social security numbers (Medicare IDs). Blank cells are acceptable.

Blank cells (where no data is available) are acceptable. U

Contact Date

Set the filter, view this field, and verify that the dates are within the measurement period. Blank values will create an ERROR upon submission.

V

PHQ-9 Score

Set the filter, view this field, and verify that the scores are whole numbers and that there are no scores over 27.

W

Exclusion Reason

Verify that each cell is one of the accepted codes.



Quality Check

X

Verify that date is within the measurement period and that this cell is populated if the “Exclusion Reason” cell is populated.

Exclusion Date

Other: 1. Exclusions 2. Hyphens or “0”s 3. Blank rows in spreadsheet

1. Verify that excluded records are removed and recorded on Exclusions Template. Please see Table 2 on pages 7-8 for all applicable codes used to identify patients who meet exclusion criteria. 2. If the data field is supposed to be blank, do NOT enter hyphens or zero (leave blank). 3. Check that the Excel file does not have blank rows at the bottom of the spreadsheet. Blank rows can slow the data submission process. To check for blank rows: Press Ctrl/End at the same time to go to the bottom-most cell in the spreadsheet. If there are several blank rows, remove them by highlighting the BLANK rows, right clicking in the left margin, and select Delete (this deletes the rows and not only the text within the cells).

Additional Quality Check Questions In addition to the quality checks above, prior to upload please double check that your process was correct by answering the following questions:  Did you use the same patient ID for patients that were already submitted to the data portal?  Is the file sorted by patient ID and then contact date (oldest to newest)?  Did you include ALL follow-up PHQ-9 scores for patients that were indexed in this period or prior periods regardless of low PHQ-9 scores, non-face-to-face visits or visit diagnosis codes? Did you include scores from scanned PHQ-9s, flowsheets, or visit notes?  Does your excel file match the depression data collection spreadsheet template (the formatting and column headers)? If you answered “NO” to any of the above questions, please return to the data file and correct the issues. Optional Quality Check: Complete an Audit of Clinical Data: Another option is to select a random sample of several records (about 30) and audit those records to see if the data matches what was collected from the patient record. If errors are found, make the corrections in the Excel file, however also consider if the errors were isolated cases or indicative of a larger data collection problem.



Step 5: Data File Creation and Data Submission Important note for those submitting all three files in February 2013 at one time: 

If you collected your data on one spreadsheet for all 2012-2013 dates of service, before you begin this step, please sort by contact date and create three separate files for each measurement period. Then continue on below with the final quality checks and data submission steps for each of your three data files.



You must work sequentially through each of the three periods. Please enter your population counts and upload your file for the 02/01/2012 to 05/31/2012 period and complete that step (clicking submit data to MNCM) before you begin to enter the population counts for the 06/01/2012 to 09/30/2012 period. Then complete the 06/01/2012to 09/30/2012 data file submission before starting the 10/01/2012 to 01/31/2013 data file submission.

Final Steps to Complete in the Excel File: Before proceeding with the file submission, be sure to:  Complete all data collection and data entry.  Complete data quality checks.  Combine all clinic files onto one spreadsheet. All clinics must be uploaded in one, single spreadsheet. The clinic identifier is the Clinic ID.  Verify that each column is formatted according to measure specifications (TEXT, NUMBER, or DATE formatting). Columns can remain at any width.  Check that the field labels in the header row (very top row) matches the labels on the Excel template exactly.  Ensure that all original columns remain in the spreadsheet even if there is no data. Do NOT delete any columns. If at any point in the process it is discovered that corrections to the data are needed, make the necessary changes in the Excel file and save.

Important Message Regarding the CSV File: After creating the CSV file, do NOT open the CSV file in Excel. Opening the CSV file in Excel destroys the formatting and alters the data. To view the data again, open the original Excel file. If you need to make changes to your file, make the changes in your original excel file, not in the .csv file, and save the changes to a new .csv file. If the CSV file is mistakenly opened in Excel, simply re-save a new CSV file from the original Excel file. Rename the old CSV file or delete it entirely. What is a CSV file? Why is a CSV file needed for data submission? CSV stands for “comma separated values.” A CSV file is a common and simple format that is used to import /transport data between systems or software applications that are not directly related (e.g., from a spreadsheet to a database). Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. 46

Depression Care Measures 2013 Direct Data Submission Direct Data Submission Instructions Instructions for Safe Sorting in Excel These steps will need to be repeated for each measurement period. 



Excel 97-2003 o

In the upper left hand corner of the spreadsheet between Column A and Row 1 there is a blank gray cell. Click on this cell to highlight your entire spreadsheet. If you do not highlight every row and column you could lose the integrity of your data.

o

Go to the menu bar and select Data and then Sort. This will bring up a window that asks what fields you wish to sort by.

o

In the first box select “PatientID” and “ascending”. In the second box select “Contact Date” and “ascending”. The data range defaults to selecting a “Header Row” and this is fine. Select the “OK” button and the records will sort in the correct order.

Excel 2007 and 2010 o

Same as 97-2003 except the pop up window is different. In the drop-down box select “PatientID” and “smallest to largest”. Then add a second level and select “Contact Date” and “oldest to newest”. The data range defaults to selecting a “Header Row” and this is fine. Select the “OK” button and the records will sort in the correct order.


Depression Care Measures 2013 Direct Data Submission Direct Data Submission Instructions Create CSV File for Data Submission The next step is to create a CSV file that will be used for upload to the MNCM Data Portal. Below are steps for creating a CSV file (Excel 2003, 2007 or 2010 users). These steps will need to be repeated for each measurement period. For Excel 2003 Users

For Excel 2007 Users

For Excel 2010 Users

1. Open the original Excel file (.xls) and do the following: 2. Click Edit or right-click the tab of the spreadsheet you wish to save (near the bottom of the screen)

2. Right-click the tab of the spreadsheet you wish to save (near the bottom of the screen)

2. Right-click the tab of the spreadsheet you wish to save (near the bottom of the screen)

3. Select Move or Copy Sheet



4. To book (new book) – this is a drop-down selection

4. To book (new book) – this is a drop-down selection

5. Select Create a Copy and click “OK.”

5. Select Create a Copy and click “OK.”

6. In this new book, click the Office Button (upper left-hand corner of screen); Select Save As

6. In this new book, click the File tab (upper left-hand corner of screen); Select Save As

4. To book (new book) – this is a drop-down selection 5. Create Copy (check this box) 6. In this new book, click File, Save As

7. Select the folder and file name of your choice. 8. At the very bottom, you will see Save as type; choose from the drop-down menu, CSV (comma delimited). 9. Click Save. When you save the CSV file, the following warning will appear: “…may contain features that are not compatible with CSV. Do you want to keep the workbook in this format?” Click Yes. 10. Now you can close the file; a message will appear: “Do you want to save this file...?” Click either yes or no. Your CSV file is now ready for upload to the MNCM Data Portal. Do NOT open the CSV file in Excel. If the file is mistakenly opened, simply resave a new CSV file.


Depression Care Measures 2013 Direct Data Submission Direct Data Submission Instructions Data File (.csv) Upload to the MNCM Data Portal The last step is to upload the CSV file to the MNCM Data Portal. Go to the HOME tab on the data portal and scroll down to the correct Depression measure period. REMINDER: You must submit the depression data files in chronological order. Click on DATA SUBMISSION and follow the steps below.

Step 1 Enter in your clinic level population counts







REL Data Collection: Please indicate if you collect race, Hispanic ethnicity, preferred language and country of birth using best practice methods. Best practice methods include: o

Hispanic Ethnicity and Race: Allowing patient to self-report race AND not using a multiracial category AND system allows the collection and reporting of more than one race

o

Preferred Language and Country of Birth: Allowing patient to self-report these demographic data

Clinic Level Population Counts: o

Clinic Level Population Count 1: Total Adult Patients

o

Clinic Level Population Count 2: Total Adult Patients with Depression Diagnosis (296.2x, 296.3x or 300.4)

o

Clinic Level Population Count 3: Total Adult Patients with Depression NOS (311) code

o

Clinic Level Population Count 4: Total Adult Patients with a Completed PHQ-9 AND diagnosis of Major Depression or Dysthymia (296.2x, 296.3x or 300.4)

Not Depression Patients with Diagnosis of 296.2x, 296.3x or 300.4 Seen this Period: Check this box if a clinic is not reporting for this cycle of data collection. o

Provide a reason the clinic is not reporting. For example: The clinic has no patients meeting eligibility criteria.


Depression Care Measures 2013 Direct Data Submission Direct Data Submission Instructions Step 2 Review and Save Verify the numbers entered by reviewing all of the clinic site’s information for accuracy (no typos or duplicate patients). Click Save and Continue, or click Back to Step 1 to re-enter the counts.

Step 3 Upload Data Click Browse to search for the CSV file and click Upload CSV and Continue. The portal will now scan the CSV file to identify possible errors. The portal will then provide an “Upload Status” that will indicate if there are errors or warnings in the data file. You may have to click on Refresh. If there are errors, the data file will need to be corrected and resubmitted to portal. Please refer to the Data Elements and Field Specifications (pages 11-18) to review the required data for each column. 1. Errors: Corrections must be made and a new file uploaded (example: portal finds a date of birth that is out-of-range). Proceed to Steps 3 or 4 below as appropriate. 2. Warnings: Review possible errors and decide whether corrections are needed (example: portal finds the number of stool tests returned is listed as 0.1 and it should be a whole number like 1). If corrections are needed, proceed to Steps 3 or 4 below as appropriate. If corrections to the data file are necessary: To start from Step 3: If corrections need to be made to the data file, make corrections in the original Excel file and save; then save a new CSV file to upload. Do NOT make corrections in CSV file as this will destroy the format and alter the data. Click Re-Upload Data File to begin again with Step 3 Upload Data. To start from Step 1: Click Clear & Start Over to start the process completely over from Step 1 Enter Denominator. NOTE: All number entries and a new file upload will be necessary. Once the Data (.csv) File has been uploaded to the portal, click Continue to Step 4.

Step 4 Review & Submit Please review the current measurement period’s preliminary rates for each clinic compared to the last data submission for this measure and consider any changes between the current period and the prior period. Provide an explanation in the text box for any changes or indicate that the data comparison is what you expected. 

If you need to resubmit the data file: Click either Re-Upload Data (.csv) File or Clear and Start Over at the bottom of the page.



Once you have entered an explanation, click Save Notes. The page will once again be updated to save the notes.


Depression Care Measures 2013 Direct Data Submission Direct Data Submission Instructions Step 5 Done The data file has been successfully submitted. MNCM will send an e-mail that the data has been received.



Step 6: MNCM Validation of Submitted Data After the clinical data file is successfully uploaded to the MNCM Data Portal, MNCM will contact the medical group regarding the validation audit. The validation audit is conducted to verify that the submitted data matches the source data in the medical record. The validation audit may be conducted remotely via HIPAA secure WebEx technology for groups with an Electronic Medical Record (EMR). Onsite audits will occur for medical groups with paper chart systems. a. A medical record audit will occur with a groups’ last measurement period submission in the measurement year – after the February 2013 submission. b. Medical audits may occur more frequently for groups with a history of unsuccessful direct data submissions The medical record validation audit may be conducted remotely via HIPAA secure WebEx technology for groups with an Electronic Medical Record (EMR). Onsite audits will occur for medical groups with paper chart systems.

MNCM Validation Process MNCM utilizes the NCQA (National Committee for Quality Assurance) “8 and 30” process for validation audits. The following method is used for each measure: 

MNCM randomly selects 33 records for each clinic site for validation. At most, 30 records for each clinic site will be reviewed. The additional three records requested are oversamples to ensure there will be 30 records available on the day of the review.



MNCM auditor reviews the first eight records of the clinic site’s selected sample to verify that the submitted data matches the source data in the medical record.



If all of the first eight records reviewed are in perfect compliance (100%), the clinic site is determined to be in high compliance, and the MNCM auditor may determine that no further record review for that site is necessary.



If the first clinic site is in high compliance and the data collection process for all clinic sites within the medical group is identical, further review may be abbreviated at the discretion of the MNCM auditor.



If clinic sites are not in high compliance after review of the first eight records, the MNCM auditor will continue to review the remaining 22 records. If after review of all 30 records the clinic site is not in high compliance on all factors (less than 90%), the MNCM auditor will review the results with the clinic representative and communicate the results with MNCM. MNCM will then contact the medical group to develop a mutually-agreed upon re-submission plan. (Re-submission plans will only be allowed for errors in the numerator portion.)



Clinic sites that are not in high compliance or have not been in high compliance in a previous MNCM audit may be held to a more rigorous denominator certification and validation audit. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. 52

Depression Care Measures 2013 Direct Data Submission Direct Data Submission Instructions Validation Results: Once all clinics within a medical group have passed the MNCM validation process, MNCM will approve the data in the MNCM Data Portal, which generates and automatic e-mail to the medical group’s data contact that the data is verified and approved. Please maintain the data submission files and other documents for two years.

Clinic Preparations for the Validation Audit 

All medical groups should plan for a validation audit.



MNCM auditor will contact medical group to schedule the audit.



MNCM will provide list of sample records to be audited.



Medical group or clinic site representative must be available to participate in the entire audit process. o

For validation audits using an EMR, a medical group or clinic representative will retrieve and display the selected records and various screens necessary to complete the validation.



During the audit, the patient’s date of birth is used to verify the correct record. All other patient information may be blocked out.



Clinics must have the following available at the time of the validation audit: o

ALL requested patient records

o

The “crosswalk” between the unique patient identifier and the patient’s name and DOB, so that the record can be located by clinic staff at the time of validation audit



Step 7: DDS Results Following the successful submission and validation of the clinical data, medical groups can expect to see results posted in November on the MN HealthScores Web site at www.mnhealthscores.org. Results will also be included in the annual Health Care Quality Report later in the year. DDS results can also be found on the “Results” tab on the MNCM Data Portal.



Depression Specific Results: A new functionality (reporting wizard) has been developed in the Results tab of the data portal. The goal is to provide users with the following capabilities: 

Ease in selecting either process measure or outcome measure results. o o



Process measures like utilization of the PHQ-9 are based on the period that the counts are submitted. Outcome measures like remission are based on the patient’s index contact date.

Provide a patient level file back to the users; each medical group can access their own file of patients, similar to current functionality for diabetes and vascular patients. Visit level depression data that is submitted is not helpful as on output back to medical groups. This enhancement provides the information summarized by patient (initial PHQ-9, six month PHQ-9 score, achievement of remission, etc.). This could also be used to create or update a registry for groups that are not yet on an EHR.

Tip: When selecting parameters for the outcome measures, remember to specify only the index contact dates for patients that would have enough data. For example, if the most current submission is dates of service through 05/31/2012 you would need to count back seven months to get patients with enough data to measure the six month remission measure. Therefore the index contact date would need to be in a range where the upper index contact date limit is less than 10/31/2011. The portal cannot pull data it does not have, but you may think you are reporting on something other than what is available.

Pay-For-Performance Programs Medical groups will also receive individual communications from health plans and MN Bridges to Excellence regarding their pay-for-performance programs that utilize DDS results.



Appendices


Depression Care Measures 2013 Direct Data Submission Appendices

Appendix A About MN Community Measurement and Measure Development Mission and Vision of MN Community Measurement (MNCM) The mission of MN Community Measurement is to accelerate the improvement of health by publicly reporting health care information. MN Community Measurement’s vision is to: 

Be the trusted source for performance measurement and public reporting of quality data across the spectrum of health care that



Drive change towards more safe, effective, patient centered, timely, efficient, and equitable care



Be a resource used by providers to improve care and patients to make better decisions



Catalyze our community to work together on health care measurement to reduce administrative costs and maximize value.

About the Measure Development Measures are selected according to MN Community Measurement’s Strategic Measurement Development Process. An impact and recommendation document presents the topic for discussion at the Measurement and Reporting Committee (MARC). Topics for measure development must meet the following criteria for consideration of development: 



Will the measure/s make a difference? o

Degree of Impact

o

Degree of Improvability

o

Degree of Inclusiveness

o

Degree of Performance Variation

o

Outcome measures desired

Will the measure improve care by affecting the patient/ physician relationship? o

Pass the feasibility test (resources/ barriers/ culture)

o

Fit with National, Regional and Local Priorities

o

Relevant to consumers

o

Support and enhance the patient/ provider relationship


Depression Care Measures 2013 Direct Data Submission Appendices Impact of Major Depression and Dysthymia According to National Institute of Mental Health (NIMH), 6.7 percent of the U.S. population ages 18 and older (14.8 million people) in any given year have a diagnosis of a major depressive disorder. Major depression is the leading cause of disability in the U.S. for ages 15 - 441. Additionally, dysthymia accounts for an additional 3.3 million Americans. The Center for Disease Control and Prevention states that 15.7% of people report being told by a health care professional that they had depression at some point in their lifetime. Persons with a current diagnosis of depression and a lifetime diagnosis of depression or anxiety were significantly more likely than persons without these conditions to have cardiovascular disease, diabetes, asthma and obesity and to be a current smoker, to be physically inactive and to drink heavily.2 Suicide rates for Minnesotans are 10.4 per 100,000 or 1.3 suicides per day, with the highest rates among the following groups: Males (4 times greater than females), ages 30 to 49 years, and non-Hispanic whites.3

Depression Care in Minnesota Efforts to improve care and outcomes for patients with depression have been accelerated in Minnesota by two related initiatives. DIAMOND- “Depression Improvement Across MN, Offering a New Direction” is a new care model with payment restructuring and outcome measurement; primary care clinics are participating in this project. MN Community Measurement (MNCM) is partnering with Bridges to Excellence (BTE), Minnesota Department of Health and other payers to provide depression outcome measurement for all adults with major depression or dysthymia who are treated in a primary care or behavioral health setting. Patient outcomes for both of these initiatives are tracked according to the patient’s PHQ-9 depression scores over time.

What is the difference between DIAMOND and MNCM Depression? Measures for the two initiatives are the same in terms of six and twelve month outcomes for depression; however, the patient populations are slightly different. DIAMOND is measuring those patients who agree to be in the new care model, whereas MNCM measures are applied the whole adult population of patients with major depression or dysthymia. DIAMOND clinics that want to participate in the BTE program need to submit data for all their patients with depression. DIAMOND is also capturing additional measures for the care management process. For more information about the DIAMOND initiative, please access the ICSI website at www.icsi.org.

1

National Institute of Mental Health www.nimh.nih.gov “The Numbers Count: Mental Disorders in America” 2008 Centers for Disease Control and Prevention 2006 Behavioral Risk Factor Surveillance 3 Suicide Prevention Resource Center www.sprc.org/stateinformation “Minnesota Suicide Prevention Fact Sheet” Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. 58 2

Depression Care Measures 2013 Direct Data Submission Appendices DIAMOND  Only reporting for patients with depression and a PHQ-9 score greater than nine who opt in to the care model  Partial population reporting  Monthly Data Collection  Additional data elements and measures

MNCM Depression  All patients with major depression and a PHQ-9 score greater than nine  Full population reporting  Data collection three times/ year (or annual submission of three separate files)

So, for those clinics participating in DIAMOND  Submit all your patients with depression, not just those who enrolled in DIAMOND

How is the Depression Submission Different from Other DDS Measures?

Example: Diabetes Measure

Depression Measure

 A snapshot with a retrospective look back  Over the last year what was the value of the most recent A1c  File = Patient Level Records; one row for each patient  Annual submission

 Prospective, looking forward. Longitudinal over time  Patients meet inclusion criteria and then measured for outcome at six months  File = Visit Level Record; a single patient has many rows  one for each contact with PHQ-9 test administration  Three times a year submission (Or annual submission of three separate files)



Appendix B Explaining the Depression Measures and Submission to Providers and Clinical Staff Here are some talking points to help explain this process to providers and clinical staff: 

These measures apply to patients who are diagnosed with major depression or dysthymia; either newly diagnosed or have existing depression.



If you are coding a patient’s visit as 296.2x, 296.3x or 300.4, the codes for major depression or dysthymia, then you should also be using the PHQ-9 tool.



Need to have both of the following: A confirmed diagnosis of major depression or dysthymia and a PHQ9 score greater than nine in order to be eligible for the measure denominator. Patients are not eligible to be included in the measure denominator based on PHQ-9 score alone.



For behavioral health providers, the diagnoses need to be in the primary position. For primary care providers, the diagnoses are either primary or secondary (any position).



It is an expectation that patients with major depression or dysthymia are assessed on an ongoing basis using the PHQ-9 tool and that the PHQ-9 is used with every patient visit; however MNCM cannot dictate how frequently you administer the PHQ-9 to your patients. It is our experience that groups that are only trying to obtain a six month score miss the benefits re-assessment of patient status and need for intervention sooner that the point of measurement.



Once the patient is identified as having depression and an elevated PHQ-9 score (inclusion criteria), then any time a PHQ-9 is administered, the score needs to be included in the submission, regardless of the reason for the visit/contact.



Each patient’s starting point is different (index visit). For the six month remission measure, a window of time is allowed to connect with the patient, either 30 days prior to the six month date or 30 days after the six month date. It takes seven months of data collection to report the outcome of the six month measure. The data portal calculates the reporting period for each patient by date. Only scores within this 60 day window “count” towards measuring remission. The most recent PHQ-9 score within this window is the score that will be used.



Remission is defined as a PHQ-9 score of less than five. This corresponds with the validated PHQ-9 tool interpretation of scores: o o o o o

0 to 4 5 to 9 10 to 14 15 to 19 20 to 27

No depressive symptoms Mild depression Moderate depression Moderately severe depression Severe depression


Depression Care Measures 2013 Direct Data Submission Appendices 

Patients who are not assessed within the 60 day window are considered to “not be in remission” and are counted in the denominator of the remission measure.



Rate is calculated as follows:

# adult pts with a PHQ-9 score < 5 at 6 months (+/- 30 days) # adult pts with depression with index contact PHQ-9 > 9

X 100



The data file is structured at the visit/contact level. For example, a patient seen and assessed in February, June and August would have three records in the file, one for each PHQ-9 score obtained.



There are several measures that are captured through a single file submission process. Please see Appendix C.



Appendix C Suite of Available Depression Care Measures The following is a list of measures for the depression population. All of these measures are calculated based on the population counts and file submission of patients meeting inclusion criteria, no additional calculations or submissions are required from the medical groups. Not all measures will be used for public reporting or payer reward programs, but all rates will be available to the medical groups for internal use and quality improvement purposes.

#1

Measure and Purpose

Definition

Reporting*

Percentage of the adult population with major depression or dysthymia during the measurement period

Adults age 18 and older with a diagnosis of major depression or dysthymia with at least one visit to a billable/ eligible provider during the measurement period. ICD-9 codes:

Internal

Prevalence of depression Calculated from clinic level population counts

o o o

296.2x - Major Depressive disorder, single episode 296.3x – Major depressive disorder, recurrent episode 300.4x – Dysthymic Disorder # adult patients with depression (296.2x, 296.3x and 300.4) total # adult patients

#2a

Percentage of the adult population with unspecified depression diagnosis during the measurement period

Adults age 18 and older with a diagnosis of Depression; Not Otherwise Specified with at least one visit to a billable/ eligible provider during the measurement period ICD-9 codes: 311 - Depressive disorder, not elsewhere classified # of adult patients with diagnosis of depression not elsewhere classified (311) # total adult patients

Calculated from clinic level population counts

Note: If a patient has both codes during the measurement period (311 and one of the major depression or dysthymia codes) count the patient as having major depression or dysthymia, not depression NOS


Internal

Depression Care Measures 2013 Direct Data Submission Appendices Measure and Purpose #2b Percentage of the adult population with depression who have unspecified depression diagnosis during the measurement period Potential for overuse of 311

Definition

Reporting*

Adults age 18 and older with a diagnosis of depression during the measurement period. This measure is tracking the rate of the use of 311 unspecified depression as a percent of all patients diagnosed with depression.

Internal

# of adult patients with diagnosis of depression not elsewhere classified (311) (# adult patients with 311) + (# adult patients with 296.2x, 296.3x and 300.4)

Calculated from clinic level population counts #3

Percentage of the adult population with major depression or dysthymia who had a PHQ-9 during the measurement period

Percent of patients with a diagnosis of major depression or dysthymia (296.2, 296.3 or 300.4) with a completed PHQ-9 during the measurement period. This measure is determining the rate of the use of the PHQ-9 tool for the medical group’s population of patients with major depression or dysthymia.

Process supporting implementation and use of PHQ-9

# adult pts with depression (296.2x, 296.3x and 300.4) who had a PHQ-9 administered

Public

# adult patients with depression (296.2x, 296.3x and 300.4)

Calculated from clinic level population counts #4

Percentage of the adult population with major depression or dysthymia whose index PHQ-9 score is greater than nine

Percent of patients with a diagnosis of major depression or dysthymia (296.2, 296.3 or 300.4) with a completed PHQ-9 during the measurement period whose PHQ-9 score is greater than nine.

Calculated from clinic level population counts and patient level file

# adult pts with depression (296.2x, 296.3x and 300.4) who had a PHQ-9 administered

# adult pts with depression (296.2x, 296.3x and 300.4) and PHQ-9 > 9 Note: Index contact is the first contact with confirming diagnosis and PHQ-9 score is greater than nine; serves at the starting measurement point for each patient included in the denominator.


Internal

Depression Care Measures 2013 Direct Data Submission Appendices Measure and Purpose

Definition

Reporting*

Six month PHQ-9 scores are calculated from the index contact date with a “grace period” of 60 days, + 30 or - 30 days from the date of the index contact. The most recent PHQ-9 score within this window is the score that will be used. #5

PHQ-9 follow-up assessment at six months Process supporting the achievement of the outcome of remission

Percent of patients with a diagnosis of major depression or dysthymia (296.2, 296.3 or 300.4) and a PHQ-9 score at the index contact is greater than nine who have a follow-up PHQ-9 test at six months from the index contact date.

Internal

# adult pts with depression and PHQ-9 > 9 who have 6 month PHQ-9 (+/- 30 days) # adult pts with depression with index contact PHQ-9 > 9

Calculated from patient level file #6

PHQ-9 with a 50 percent or more decrease in score (response) at six months Intermediate outcome measure towards the goal of remission Calculated from patient level file

#7

PHQ-9 score < five (remission) at six months Outcome measure demonstrating improvement in depression symptoms Calculated from patient level file

Based on the denominator of patients with major depression or dysthymia (296.2, 296.3 or 300.4) whose initial PHQ-9 is greater than nine, the percent of patients who have a reduction in their PHQ-9 score at six months by 50 percent or greater. For example, if a patient’s initial PHQ-9 was 21 and the six month PHQ-9 is 10, this patient has achieved a response outcome.

Public

# adult pts with >/ = 50% decrease in PHQ-9 score at 6 months(+/- 30 days) # adult pts with depression with index contact PHQ-9 > 9 Based on the denominator of patients with major depression or dysthymia (296.2, 296.3 or 300.4) whose initial PHQ-9 is greater than nine, the percent of patients whose six month PHQ9 score is less than five. For example, if a patient’s initial PHQ-9 was 10 and the six month PHQ-9 is 3, this patient has achieved a response outcome. # adult pts with a PHQ-9 score < 5 at 6 months(+/- 30 days) # adult pts with depression with index contact PHQ-9 > 9


Public and Payer Reward Programs, Required for MDH

Depression Care Measures 2013 Direct Data Submission Appendices Measure and Purpose

Definition

Reporting*

12 month PHQ-9 scores are calculated from the index contact date with a “grace period” of 60 days, + 30 or - 30 days from the date of the index contact. The most recent PHQ-9 score within this window is the score that will be used. #8

PHQ-9 follow-up assessment at twelve months Process supporting the achievement of the outcome of remission

Percent of patients with a diagnosis of major depression or dysthymia (296.2, 296.3 or 300.4) and a PHQ-9 score at the index contact is greater than nine who have a follow-up PHQ-9 test at twelve months from the index contact date.

Internal

# adult pts with depression and PHQ-9 > 9 who have 12 month PHQ-9 (+/- 30 days) # adult pts with depression with index contact PHQ-9 > 9

Calculated from patient level file #9

PHQ-9 with a 50 percent or more decrease in score (response) at twelve months Intermediate outcome measure towards the goal of remission

Based on the denominator of patients with major depression or dysthymia (296.2, 296.3 or 300.4) whose initial PHQ-9 is greater than nine, the percent of patients who have a reduction in their PHQ-9 score at twelve months by 50 percent or greater. This is the definition of a response. For example if a patient’s initial PHQ-9 was 16 and the twelve month PHQ-9 is 8, this patient achieved a response outcome.

Calculated from patient level file

# adult pts with >/ = 50% decrease in PHQ-9 score at 12 months

Public

# adult pts with depression with index contact PHQ-9 > 9 #10 PHQ-9 score < five (remission) at twelve months Outcome measure demonstrating improvement in depression symptoms Calculated from patient level file

Based on the denominator of patients with major depression or dysthymia (296.2, 296.3 or 300.4) whose initial PHQ-9 is greater than nine, the percent of patients whose twelve month PHQ-9 score is less than five. For example if a patient’s initial PHQ-9 was 11 and the twelve month PHQ-9 is 4, this patient achieved a response outcome. # adult pts with a PHQ-9 score < 5 at 12 months # adult pts with depression with index contact PHQ-9 > 9

* The following are definitions of reporting audiences: Internal = Medical groups will see their own results and data may be used for reporting at a summary statewide level, but not used for public reporting at a clinic site level. Public = Measure rates will be reported publically by clinic site on the MNCM website and in the Health Care Quality report Payer = Measure rates will be used for payer reward programs


Public