approve the minutes of November 1, Lisa Lokken 20 hours, Cindi Jungwirth 1 hour. Announcements and discussion

Transcription

1 Minutes of the Perinatal Data Committee February 7, 2017, 10 a.m.-2:30 p.m S. Paterson St., Suite 250, Madison, WI Participants: Lisa Lokken, Chair, Ascension- St. Joe s, Milwaukee Allen Cooper, Ancilla Partners, Milwaukee Kathy Gollmar, Unity Point Health Meriter, Madison Sue Ihde, Aurora Healthcare, Milwaukee Rachel Juckem, Aurora Oshkosh Cindi Jungwirth, Affinity Health, Oshkosh Jennifer Konrad, Froedtert Community Memorial, Menomonee Falls Kathy Kostrivas, UnityPoint Health Meriter, Madison Margaret Malnory, Ascension All Saints, Racine Courtney Pickar, Waukesha Memorial, Waukesha Guest: Janice Valenzuela (DHS HIV); Madison Fuelling (Ancilla) by phone Staff: Ann E. Conway Agenda Item Discussion Decision/Action Call to order L. Lokken called the meeting to order at 10:08 and welcomed members and guests. Welcome and Introductions Members did self-introductions. Approval of minutes Motion made, seconded, and passed to approve the minutes of November 1, Volunteer hours Lisa Lokken 20 hours, Cindi Jungwirth 1 hour. Announcements and discussion Status of report of baseline perinatal health indicators from hospital data from PeriData.Net : A draft report is ready for additional review. A.Conway asked for volunteers to review. K. Kostrivas and M. Malnory volunteered. In addition, Ann will send the draft to Marianne Weiss. Status of Data to Inform report on perinatal hypertension in conjunction with WisPQC: A draft report is ready for external review. Committee members suggested sending the report to Kathy Frigge at A. Conway will send the perinatal health indicators report to K. Kostrivas, M. Malnory, Angie Rohan, and M. Weiss. A. Conway will send the hypertension report to K. Frigge, R. Eberhart, and A. Rohan. 1

2 TJC measure information February 2017 publication of new information projected to start for 7/1/17 discharges UnityPoint Meriter and Rebecca Eberhart at Aurora Sinai, as well as Angie Rohan. Add two standard reports to PeriData.Net : This has been completed. The report is called WisPQC Summary. Under that summary are two reports, one for hypertension (HTN) and one for human milk feeding (HMF). There are patient level detail reports in both HTN and HMF. Webinars on using PeriData.Net for 2017 WisPQC project As many babies as possible receive breast milk. L. Lokken reported the TJC has not published February changes. The electronic submission algorithm may be different for the CMS algorithm. L. Lokken asked for input about where things do not match up. C. Jungwirth reported the TJC and CMS numbers for EED do not match up because practitioners do membrane stripping in the office, and PDN cannot capture that information. Stripping membranes is considered induction. There was discussion of how to capture those data in PDN. The measure is about those who deliver before 39 weeks. The committee wants to figure out how to make PDN marry up with CMS and TJC. Options are to either build something new or edit what is already in PDN. C. Jungwirth brought to Lisa s attention that the numerator and denominator are not the same in PDN as in WHA, which uses TJC. A. Conway will send list of HMF hospitals and agencies to A. Cooper. There is no need for new Webinars. Ancilla and WAPC will direct people to the archived Webinars about the HMF initiative of November and December 2016 at Membrane stripping for induction of labor. Madison Fuelling and A. Cooper will work on possible options, which Lisa will send to the group for feedback. The goal is to resolve the issue ASAP. The numbers are correct, but the definitions in PDN are not consistent. Ancilla will change the definition in PDN to match TJC and then apply to CheckPoint. 2

3 Ancilla report Completed items: o Added link in the new user password to the training webinar on the WAPC Web site. o Continued to add new fields and adjustments to the WISPCQ reports technically, all of the new Breastfeeding initiative by WisPQC is new since the last meeting, with all 12 new fields. Ancilla also rolled out the fields and then gave hospitals one month until they were required. o Navigation filters and Home Page by area/project WisPQC filter is live only see fields that are incomplete in WisPQC. If WisPQC is turned off, the filter goes away. WHA filter is in test only see records and fields that are incomplete in CheckPoint. o Created a facility WisPQC flag to help control the required fields for the project. It also controls the display of the WisPQC Nav filter. o Infant Discharge Pending field was added o Added antiphospholipid antibody field back into EED measures for the reports. o Confirmed with WHA that the infant discharge date for PC05 and infant complication will be used beginning Q The reports have been updated to reflect this. o Field List (Data dictionary) can be filtered by reports. Get to this as part of standard reports. o CSV Upload Production - Currently have 13 facilities using this upload process Development Working Wheaton (4) 7 other facilities have expressed interest Expanded fields - Ancilla added Skin-to-Skin Initiation, County and State for mother Talk offline about whether to take hospitals off if they are not part of HTN or HMF. Get the word out to users about this. Other fields in test. Ancilla 3

4 address, Infant first and last name. All of these are in production. Ancilla Q Items Submit WHA Checkpoint Measures Submit HIV Measures to DHS Add numerator and denominator by measure columns in Field List filterable excel report to help user determine which fields are related by a given measure. This item is almost done. There will be additional columns, and users will have the ability to filter on the new columns Submit Training Schedule to facility security officers via and also have it on the WAPC Web site. Need to work with WAPC to setup the actual webinars. o Would 2 nd week of each month, on a Tuesday at noon be the best option? communicates with security officers and puts note on front page. The Committee agreed that the second Tuesday of each month at noon would work well. Ancilla and WAPC will set up a schedule, which will be on the WAPC and PeriData.Net Web sites. The Webinars are Intended for people doing data entry and running reports. They will be how to sessions for new people in hospitals. (Note: The training dates follow: February 14 March 14 April 18 May 16 June 13 July 18 August 15 September 12 October 17 November 14 December 12 ) Bring standard reports back into PDN, rather than having to go into Pentaho all reports summary and patient level. The plan is to mimic what PDN used to do. M. Fuelling will set up a priority list and send to the group for feedback. Ancilla will 4

5 probably have top 5 quick report access on the nav and have a new landing page to display the remaining reports. Turn off old fields not being used based on field usage analysis Continue to grow CSV upload fields, targeting as many SVRISrequired fields as possible. CSV Upload Batch Process - Turn into a batch process, where the hospital sends a service call to an address, similar to SVRIS to send data. This would be more secure and easier to setup. This process does not store a file on a server. Work on process to send data to VON from PeriData.Net. Eleven PDN hospitals participate in VON. A. Cooper has been talking with a VON staff person who suggested using enicu to create a CSV. There are 24 fields in PDN that align with VON. Is there value to create a CSV upload to start the process? Does this add value? Currently, data sharing is completely manual. Ancilla will build a CSV report that a group can upload into the enicu software. Ancilla will work with VON to receive data from them. Allen will follow up with VON. L. Lokken asked about a calculation that could be added to PDN to count babies who die in the delivery room and never get admitted to an NICU. The data are in PDN, but VON people don t have access to the data. Could this be included in the data extract that Ancilla builds? SVRIS Continue discussion to send the state data in Q2. The goal is to turn on a data loop to and from SVRIS. Discussion: o Customizable fields: Ancilla could create a form at the facility level to allow a facility to determine which measures it would like to be a part of. This form and the overall measure list would dictate which fields are required for an individual hospital. Once a hospital selects its measures, it could get a list of fields that would become their worksheet. A. Cooper provided a Figure out if and how to operationalize this in the next couple of months. 5

6 handout of a field usage analysis broken down by number of fields not used and size of hospital for one year. He divided the fields by what percent of hospitals did not use particular fields. For example, there are 25 fields that 90% of hospitals do not use and 45 fields that 80% of hospitals do not use. Allen asked the Committee to provide feedback about the analysis. He needs input to know what fields to remove, hide, or add. Summary reports Ancilla is adding OB primary care provider and multi-facility filter options, in addition to Attendant ( which is included already) to all reports. All reports will have the same filtering functionality. Fields to add: Opioids and NAS: A. Conway described a grant about NAS surveillance that required some of the fields in PDN, but additional fields as well. The Committee had reviewed the grant guidance, Building on Existing Infrastructure of Population-based Birth Defects Surveillance Systems to Estimate the Incidence of Neonatal Abstinence Syndrome (NAS) and discussed possible fields to add to PDN. Was baby diagnosed or observed for NAS? What was the treatment? What is the definition of NAS? Kyle Mounts joined the discussion. The Committee agreed that opioid withdrawal be included in the definition. Define treatment with Finnegan scores, comfort care, and pharmacological intervention. Opioids should be added as a choice in the mother s drug list. Additional information for newborns: The Committee considered the following list: Proposed additional information for newborns: Neonatal Procedures Percutaneous Central Venous Line (PCVL) Field Usage Analysis: Ancilla anticipates sending this in the next week. Ancilla will implement in Q1. Committee members R. Juckem and C. Pickar volunteered to work with Kyle Mounts and A. Conway to develop a list of fields to be considered by the Committee. Committee members will review the list and come to the next meeting prepared to make decisions about which items and fields to include in PDN. 6

7 WHA report none DHS report--none Nitric Oxide Steroids for Chronic Lung Disease (CLD) PDA Ligation CPAP (consider adding underneath Ventilation I ve been defining Ventilation as intubated (SIMV) ventilation Finnegan Scoring for NAS Pneumothorax K, Gollmar suggested adding this. Conditions of Newborn: Pulmonary Hemorrhage Chronic Lung Disease Intrauterine Growth Retardation (IUGR) Gastric Reflux / Feeding Intolerance/ difficulty feeding Patent Ductus Arteriosus (PDA) Retinopathy of Prematurity (ROP) -- Grades 1 4 Inguinal Hernia Wet Lung Differentiate between non-pharmacologic and pharmacologic treatment for Neonatal Abstinence Syndrome Persistent Pulmonary Hypertension (PPHN) New discussion LGA and SGA: These fields are necessary to determine the appropriate use of glucose gel. This item should be dealt with quickly. Practitioners need gestational age, weight, and mother s history of diabetes. PDN also need glucose gel added as a treatment option. As of 1/1/17, all discharge data will be based on Mother s and Baby s date of discharge. L. Lokken suggested that we consider adding data fields related to long acting reversible contraceptives (LARC). C. Pickar uses billing data for LARC numbers, since it is billed separately. Could some sort of CSV upload from billing or coding be used in PDN to enhance functionality? The issue is not just the number of women getting LARC immediately postpartum, but how does that procedure affect short and long-term S. Ihde, J. Konrad, and L. Lokken will propose the fields to be added. 7

8 outcomes, such as Interconceptional interval, term/preterm baby, kind of LARC, etc. How do we want information about the use of LARC to inform care, esp. with subsequent pregnancies? Next meeting The Committee provided positive feedback about the timed agenda: March 22, 10-2:30 p.m. The meeting ended on time and it helped to manage discussions. Adjournment L. Lokken adjourned the meeting at 2:20 p.m. and thanked members for their participation. Notes respectfully submitted by Ann E. Conway G:\Perinatal Data\minutes\2017\February 7 Final.docx 8