DATA COLLECTION GUIDE Direct Data Submission. Total Knee Replacement (TKR): Functional Status and Quality of Life Measures

Transcription

1 DATA COLLECTION GUIDE Direct Data Submission Total Knee Replacement (TKR): Functional Status and Quality of Life Measures () Data Submission: 04/13/2015 to 05/15/2015

2 Table of Contents Process and Timeline Overview... 3 Measure Specifications... 4 Summary of Changes... 5 Codes to Identify Patients who underwent Total Knee Replacement Procedure... 8 Table 1: CPT Codes for Identifying Primary Total Knee Replacement Procedures...8 Table 2: CPT Codes for Identifying Revision Total Knee Replacement Procedures...8 Measure Logic/Flow Chart Data Collection and Submission Preparations and Considerations Section A: Identifying the Initial Patient Population Section B: Data Collection Data Elements and Field Specifications Summary of Changes Section C: Data File Creation Section D: Data File Submission Section E: Data Validation Appendices Appendix A: Patient Reported Outcome (PRO) Tools Appendix B: Facility Codes Table 3: Hospital Facility Codes Table 4: Freestanding Outpatient Surgical Centers Appendix C: Additional Measures Appendix D: MNCM Data Portal Registration Appendix E: Resources to Help You Get Started Appendix F: About Direct Data Submission (DDS) Appendix G: About MN Community Measurement and Measure Development Page 2

3 Process and Timeline Overview 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. Resource: Download Clinic & Provider Registration Instructions from the RESOURCES Tab on the MNCM Data Portal or Medical Groups must register prior to submitting data. NOTE: Medical groups only need to register once for each report year. If changes occur within a medical group (e.g., clinics closures) after registration and during the report year, contact MNCM Support. Pre-Submission Data Certification (formerly Denominator Certification) Medical groups submit a pre-submission data certification form outlining the method for identifying the initial patient population on the MNCM Data Portal. MNCM reviews and approves the method. MNCM must approve your presubmission data certification form before data is collected. Plan accordingly. Resources: Download TKR 2015 Pre-Submission Data Certification Template from the RESOURCES Tab on the MNCM Data Portal. Data Collection and Submission Data collection begins after the billing cycle for the measurement period is completed. Medical groups prepare and submit CSV files via MNCM Data Portal. Resources: Download Data Collection TKR 2015 and TKR 2015 Data Collection Spreadsheet Template from the RESOURCES Tab on the MNCM Data Portal. Preliminary Results Review, Quality Checks Medical groups review preliminary results internally to verify rates and provide comments. MNCM reviews preliminary results/comments. Resources: On MNCM Data Portal home page, under Data Submission. Data Validation MNCM conducts audit to validate submitted data matches the source data patient medical records. Resources: MNCM will instructions and post list of randomly-selected patients for audit on the MNCM Data Portal. Two-Week Medical Group Review Period Medical groups review preliminary statewide results prior to the public reporting of final statewide results. Resources: MNCM will Information and instructions to appropriate medical groups. Data Results After the successful submission and validation of the clinical data, MNCM may post the results on and other publications. Helpful Dates to Remember Registration begins December 15, Registration deadline is February 6, Submit pre-submission data certification document in March April 2015 MNCM responds within 2-3 business days after receiving the document MNCM Data Portal opens: April 13, 2015 MNCM Data Portal closes: May 15, 2015 Completed after data submission and prior to validation audit MNCM auditor will contact medical groups to schedule validation audit after data file is submitted. July 2015 Late 2015 Page 3

4 Total Knee Replacement: Functional Status and Quality of Life Outcome Measures 2015 () Measure Specifications Page 4

5 Measure Specifications Summary of Changes Plan for Transition to PROMIS Global-10 PROMIS-10 is replacing the EQ5D-5L patient reported outcome tool for assessing pre-operative and post-operative quality of life. This change is effective for patients undergoing a procedure as of 1/1/2015. For patients who had a pre-op assessment with EQ5D and a post-op assessment with PROMIS Global-10, conversion of values will occur within the MNCM data portal. Please refer to Appendix A and the Data and Field Specifications for more details; Appendix F for measure development work group rationale. EQ5D Versions No Longer Apply In previous submission measurement periods there was a reference to version of EQ5D (3 response version = 3L and new five response version = 5L). Complete transition to the EQ5D-5L was to occur by 1/1/2013, so all references to the old 3L versions were removed in addition to the fields for identifying version used. Optional Fields for OKS Individual Values Submitting the individual values of the OKS tool was provided as an option to groups; however only the summary OKS score is required for submission and measure calculation. Very few groups are utilizing this option; therefore optional fields will be removed from the data submission file. Description Methodology For patients ages 18 and older who undergo a primary or revision total knee replacement procedure during the measurement period, the following measures will be calculated: 1. Average change between pre-operative and one year (9 to 15 months) postoperative functional status as measured with the Oxford Knee Score. 2. Average change between pre-operative and one year (9 to 15 months) postoperative health related quality of life as measured with the EQ5D-5L. All functional status and quality of life measures will be stratified for primary knee replacement and for revision knee replacement. 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. Full population data is required. Page 5

6 Rationale Total Knee Replacement 2015 Measure Specifications Annually there are over 500,000 total knee replacement procedures performed in the US. It is projected that by 2030, the volume of this procedure will increase to over 3.48 million per year due to the aging baby-boomers, increased obesity and indications for total knee replacement that extend to both younger as well as older patients. 1 From 2000 to 2006, the Medicare total knee replacement rate overall in the United States increased by 58%, from 5.5 to 8.7 per 1, Total knee replacement revisions currently represent 8.2% of all Medicare dollars spent. 3 During this same timeframe, total knee replacement rates in Minnesota regions increased from 7.2 to 8.6 per 1,000 to 10.8 to 12.9 per 1, It is estimated that annual hospital charges for total knee replacement will approach 40.8 billion dollars annually by Procedure Measurement Period For consumers, there is a lack of publicly reported information that would provide patients with an understanding of potentially how well they will function after having total knee replacement surgery. These measures will provide outcome data for patients that currently does not exist. Measurement period will be for patients undergoing a total knee replacement procedure with a date of procedure between 01/01/2013 to 12/31/ Kurtz S. Future caseload. American Association of Orthopedic Surgeons Annual Meeting CDC. Racial disparities in total knee replacement among medicare enrollees -- United States, MMWR Weekly. 2009;58(6): Ong K, et. al. Economic burden of revision hip and knee arthroplasty in medicare enrollees. Clinical Orthopaedics and Related Research. 2006;446: The Dartmouth Institute for Health Policy & Clinical Practice. Trends and regional variation in hip, knee and shoulder replacement. Robert Wood Johnson Foundation Kurtz S, et. al. Future clinical and economic impact of revision total hip and knee arthroplasty. Journal of Bone and Joint Surgery. 2007;89(3): Page 6

7 Denominator Total Knee Replacement 2015 Measure Specifications Patients who meet each of the following criteria are included in the population: Patients age 18 years and older at the start of the procedure measurement period (date of birth was on or prior to 01/01/1995; no upper age limit). Patients who underwent a primary or revision total knee replacement with a procedure date between 01/01/2013 to 12/31/2013. Patient had a following CPT code: to 27447, 27486, See Tables 1 and 2. Eligible specialties: Orthopedic surgery Eligible providers: Orthopedic surgeons who perform total knee replacement procedures. Primary Total Knee Replacement Definition: Primary total knee replacement is the first total knee replacement for this particular knee joint. Revision Total Knee Replacement Definition: Revision total knee replacement is the replacement of the previous failed total knee prosthesis with a new prosthesis. Some of the reasons for failure include wear, loosening, infection, fracture, instability, and patient related factors. Patients with bilateral knee replacements (both knees replaced on the same day, during the same procedure) are included. This would be one procedure based record. Patients with sequential knee replacements (each knee replaced on a separate day, during a separate procedure) are included. This patient would have two procedure based records, one for each procedure. Exclusions There are no exclusions. All patients undergoing a total knee replacement are to be included. Measures 1) Average change in functional status score at one year The average change between pre-operative and post-operative functional status is calculated for patients undergoing a total knee replacement (defined by the Table 1 CPT codes) who have a completed Oxford Knee Score obtained pre-operatively and at one year (9 to 15 months) post-operatively. Rates will be stratified as separate rates (stratified) for primary knee replacement and for revision knee replacement. Page 7

8 2) Average change in quality of life score at one year Total Knee Replacement 2015 Measure Specifications The average change between pre-operative and post-operative quality of life is calculated for patients undergoing a total knee replacement (defined by the Table 2 CPT codes) who have a completed EQ-5D specified health related quality of life tool obtained pre-operatively and at one year (9 to 15 months) post-operatively. Rates will be stratified as separate rates (stratified) for primary knee replacement and for revision knee replacement. Codes to Identify Patients who underwent Total Knee Replacement Procedure Table 1: CPT Codes for Identifying Primary Total Knee Replacement Procedures CPT Procedure Codes CPT Procedure Code Description Arthroplasty, knee hinge prosthesis Arthroplasty, knee condyle and plateau, medial OR lateral compartment Arthroplasty, knee condyle and plateau, medial AND lateral compartment with or without patellar resurfacing (total knee arthroplasty) Table 2: CPT Codes for Identifying Revision Total Knee Replacement Procedures CPT Procedure Codes CPT Procedure Code Description Revision of total knee arthroplasty, with or without allograft, 1 component Revision of total knee arthroplasty, with or without allograft, femoral and entire tibial component Page 8

9 Measure Specifications Measure Logic/Flow Chart Total Knee Replacement 2015 Measure Flow Chart Please see the Data Elements Table on Pages for more detailed information about each component. Was the patient born on or prior to 01/01/1995? No Yes Did the patient undergo a primary or revision total knee replacement between 01/01/2013 to 12/31/2013? No PATIENT NOT INCLUDED IN MEASURE Yes Does the patient have one of the following CPT codes? No Yes SUBMIT ALL PATIENT DATA Did patient have pre-op OKS within 3 months prior to procedure? Yes Submit ALL pre-op and post-op functional status tools assessments Answer both questions to determine inclusion Yes Did patient have pre-op EQ5D within 3 months prior to procedure? Yes Yes Did patient have 1 year post-op OKS within 9 to 15 months post procedure? No No PATIENT NOT INCLUED IN MEASURE CALCULATION No No Did patient have 1 year post-op EQ5D within 9 to 15 months post procedure? Yes Yes Patient included in average change in functional status score at one year measure (Rates stratified by Primary vs. Revision TKR) Patient included in average change in quality of life score at one year measure (Rates stratified by Primary vs. Revision TKR) Page 9

10 Total Knee Replacement: Functional Status and Quality of Life Outcome Measures 2015 Direct Data Submission () Page 10

11 Data Collection and Submission Preparations and Considerations Before collecting and submitting data to MNCM, the following items should be reviewed. Data submission preparations Many resources can be found on the MNCM websites. MNCM recommends saving their location as favorites or bookmarks for easy future reference. o MNCM Data Portal: o MNCM Corporate Website: o MN HealthScores: A dedicated folder location on the computer or network for all data submission documents may be useful. Name versions of documents clearly, including version numbers and/or dates, to ensure use of the most recent files. Login to the MNCM Data Portal. See Appendix E for step-by-step instructions. Under RESOURCES, access Direct Data Submission (DDS) documents. o Download the following documents: Total Knee Replacement 2015 TKR 2015 Pre-Submission Data Certification Form (formerly Denominator Certification) TKR 2015 Data Collection Form TKR 2015 Spreadsheet Template Data submission considerations Patient Attribution The patient is attributed to the surgeon who performs the procedure. Total Population Submission This measure requires submission of all patients undergoing a primary or revision total knee replacement during the measurement period. All patients who meet the Initial Patient Population criteria are included in the submission for calculation of measures. Patients who may have missing assessment scores are included in the Initial Patient Population with the fields for scores and dates left blank in the submission file. The MNCM data portal assesses the presence of valid tools, values and pre-operative and post-operative time frames and calculates the Measure Denominator. The Measure Denominator, which is used to calculate the average change in functional status, pain or quality of life, only includes patients who have valid pre-operative and post-operative assessments. Process measures will be calculated to determine the rate of success in obtaining functional status assessments. Page 11

12 Using multiple data collectors Use of one data collector or data collection process is preferred as it ensures consistent methods for data collection and results in improved reliability. However, if more than one person must collect data, steps to maximize inter-rater reliability (IRR) are strongly recommended, including but not limited to training for all persons involved in data collection regarding the process and methods to be applied. Training could include a review of this guide and all related data collection forms, as well as instructions for locating information in the medical record. MNCM also recommends referring to data collection errors made in previous submissions, making plans to improve the data collection process, and performing quality checks on the data. This ensures that measurement specifications are interpreted consistently and data is collected uniformly across multiple data collectors. Page 12

13 Section A: Identifying the Initial Patient Population The first stage in the process to calculate performance scores is to identify the Initial Patient Population; the total number of patients eligible for calculation of the outcome and process measures. Patients in the Initial Patient Population who have valid pre-operative and post-operative assessments comprise the Measure Denominator used to calculate rates for the outcome measures. The denominator is the bottom number in a fraction. There is no traditional numerator or target for the outcome measures; they are calculated as an average change in the functional status, quality of life or pain score. The detailed criteria used to identify the Initial Patient Population are included in the Measure Specifications on pages 5-8. All eligible patients who meet initial patient population criteria must be identified and submitted if ALL of the following are met: Adult patients age 18 and older with no upper age limit AND Underwent primary or revision total knee replacement with a date of procedure on or between 1/1/2013 to 12/31/2013 AND Had any of the following CPT codes o Arthroplasty, knee hinge prosthesis o Arthroplasty, knee condyle and plateau, medial OR lateral compartment o Arthroplasty, knee condyle and plateau, medial AND lateral compartment with or without patellar resurfacing (total knee arthroplasty) o o Revision of total knee arthroplasty, with or without allograft, 1 component Revision of total knee arthroplasty, with or without allograft, femoral and entire tibial component There are NO upfront exclusions. Please note: Patients with bilateral knee replacements (both knees replaced on the same day, during the same procedure) are included. This would be one procedure based record for submission. Patients with sequential knee replacements (each knee replaced on a separate day, during a separate procedure) are included. This patient would have two procedure based records, one for each procedure. All patients meeting the criteria for the Initial Patient Population are included in the submission file, even if some or all of the pre-operative assessments are not completed for a patient. In the submission file when assessments are not completed, the fields for dates of assessment and scores are left blank. Process measures are calculated to determine the rate of success of obtaining pre-operative and postoperative assessments required to calculate measures of change in functional status and quality of life. Calculated exclusions following data submission: patients without a valid pre-operative and/or postoperative assessment are removed from the Measure Denominator. Page 13

14 Step 1: Pre-Submission Data Certification (formerly Denominator Certification) This must be done prior to identifying your population and collecting data. To aid medical groups identification of the correct patient population, MNCM will review each medical group s source code and/or methodology for producing the Initial Patient Population upfront. This process is intended to help identify potential issues prior to data submission, thus avoiding rework for the medical groups. However, the responsibility to submit an accurate Initial Patient Population rests with the medical group. Please contact support@mncm.org with any questions. NOTE: MNCM s pre-submission data certification process may include a comprehensive review of the steps used by the medical group to identify the Initial Patient Population, including a final listing of the identified patients. MNCM recommends saving all original queries, spreadsheets and/or other documentation of the process used to identify the patient population for potential review. Initial Patient Population Identification Methodology Details The following elements are included on the pre-submission data certification form. Medical groups will need to indicate on the form how they will identify each element. Date of Birth range. CPT Procedures codes included Procedure date range Board certified specialties of providers included in the search. The query code that you used from your billing system The pre-submission data certification step is considered complete when a medical group receives the presubmission data certification approval from MNCM. Pre-Submission Data Certification Template Form A template is provided to ensure all medical groups are using the same set of criteria to identify the Initial Patient Population. Forms must be updated on an annual basis to ensure the most up-to-date information is collected. The pre-submission data certification form requires source code or screen shots which are helpful for the certification process. Medical groups need to complete this form and submit it through the MNCM Data Portal. Page 14

15 To download the form and submit it for certification: 1. Login to the MNCM Data Portal ( 2. Go to the RESOURCES Tab and select Cycle B - Total Knee Replacement from the drop-down menu. Download the TKR 2015 Pre-Submission Data Certification 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 Total Knee Replacement 2015 Report (2013 Dates of Procedure) section on the HOME tab. 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) certify the method in the MNCM Data Portal; an automatic will notify the medical group that the method is certified. Step 2: Initial Patient Population Identification After completing Step 1, medical groups will be able to query their systems to determine the Initial Patient Population for this measure. NOTE: Medical groups that implemented a new practice management system during 2013 will need to generate the patient population list using both systems. Two queries or patient lists may be necessary; if so, the lists should be combined and a common identifier selected to de-duplicate the list. Please contact support@mncm.org with any questions. System Query If any of the following data elements are available electronically, it is helpful to include them as part of the initial data extraction from your system during population identification. Refer to the Data Elements and Field Specifications Tables found on pages for details on formatting the data elements that must be submitted to MNCM. They include: MNCM Clinic ID Facility ID (see Table 1) Patient ID number Patient Date of Birth (DOB) Surgeon NPI Number Provider type/specialty code CPT Procedure Codes: CPT codes can be helpful in designating primary versus revision total knee replacement. Diagnosis Code: Reason why the patient is having the procedure. Insurance payer: This information must be substituted with the Page 15 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.

16 MNCM-assigned insurance code in the data file that is submitted to MNCM. This should be the patients most recent insurance on or prior to the end of the measurement period which includes the follow-up time period 15 months post procedure. Insurance member ID: Do not submit Social Security Numbers. Other demographic data: Race/ethnicity, language, country of origin, gender, and zip code. Other clinical data: Height, weight, diabetes, tobacco status. Finalizing the Initial Patient Population list Once the query is completed, the file should be finalized using the following process: 1. Sort the list by clinic site and patient ID. 2. De-duplicate the list to include only one record per procedure. 3. Review the number of procedures in the population. Is the total number of procedures realistic and does it make sense? If not, does a correction in the methodology or query need to be made? 4. Make sure inactive patients are included. Patients designated as inactive in a practice management system, billing system or electronic medical record must be included in the Initial Patient Population if they meet the criteria. Excel Pivot Table Tip The Excel pivot table function can show counts of patients. Use the patient medical record number, account number or other unique ID as common identifiers. Patient Registries: A patient registry is an important tool to help clinics track patient progress and to use for quality improvement purposes. MNCM expresses caution in terms of the use of a registry as a source of data. Using a registry is acceptable only if the following conditions are met: 1. The clinic s entire population of TKR patients is included AND 2. The information in the registry is as up-to-date as the medical record. Many registries give a snapshot of patients at a given time and would therefore not include all patients according to established patient criteria or may not reflect the most recent clinical data (e.g., most recent screening exam). Registries that are programmed to update the patient population and clinical results on a continual basis (24/7) could possibly be used, however, please discuss this with MNCM. During the validation audit, MNCM auditors will review patient records for validation and not patient registries. Thus, if a clinic uses data from a patient registry, the auditor may find more validation errors. Page 16

17 Section B: Data Collection Total Knee Replacement 2015 The second stage in the process to calculate performance rates is to collect the data elements. Specific information can be found in the Data Elements and Field Specifications table on pages Medical groups can collect clinical data from medical records by it from an EMR through a data query or 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 Initial Patient Population identification method is certified by MNCM; and 3. The Initial Patient Population is pulled according to the measure specifications. Data Collection Tips: 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.) Step 1: Collect the Data Data must be submitted using the provided Excel template. It contains all of the necessary fields and column formatting to submit data according to the measure specifications. Download the TKR 2015 Spreadsheet Template from the MNCM Data Portal. It is under RESOURCES by selecting Cycle B Total Knee Replacement from the drop-down menu. 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, functional status tools contained as a part of the record, etc.). For these functional status and quality of life measures, it is unlikely that the source of information will come from any other place beside the orthopedic office s records, but in the case of potentially missing demographic or clinical information, some data can be obtained from correspondence that is included in the clinic record. If outside correspondence is used, it must be documented in the patient s medical record for validation audit purposes. Examples include height, weight, smoking status or documentation of diabetes. Please refer to the field specifications for instruction about the data collection for each field. Demographic and Clinical Information Demographic Information could be obtained from account/ billing system Clinical information can be obtained from the pre-operative assessment or pre-operative history and physical if this is contained in your record. Page 17

18 Oxford Knee Score (OKS) and EQ5D /PROMIS-10 Scores Patient Reported Outcome (PRO) assessments given to patients should become a permanent part of their medical record. Electronic Health Records: o Recommend storing values as discrete fields to allow easier extraction o Scanned assessments are an option, but may require manual abstraction to retrieve data Paper Records: o Store the assessment tools within your medical record file o It is acceptable to use an OKS summary score documented in a progress note Medical groups may elect to obtain information via a scannable form that the patient completes. This could then be used to create the data file for submission. Results from PRO Tools o For the OKS tool, only the summary scores are required for the calculation of average change in functional status. o Only submit an OKS score when the patient has answered all 12 questions, do not submit a score for a patient when the tool is only partially completed. o For the EQ5D-5L and PROMIS-10 EQ5D-5L and PROMIS-10 calculations are very complex and require individual responses to be submitted in the MNCM Data Portal for score calculation or conversion if appropriate. All of the individual scores must be submitted for these tools. The MNCM Data Portal will only accept and calculate EQ5D-5L and PROMIS-10 indexes for patients that have all questions answered. The MNCM Data Portal will convert PROMIS-10 values to an EQ5D index for all patients with a date of procedure prior to 01/01/2015. Tracking Where Data is Located in the Patient Record It is helpful during the audit process to know where data is located in the patient s medical record. If information is kept in a place in the medical record that is not typical for the practice, document the location on the data collection form or directly in the Excel spreadsheet by adding a Notes column. Save a copy of the Excel file with the Notes column (for internal records) and without (for submission to MNCM). Page 18

19 Data Elements and Field Specifications Use this data elements and field specifications section to enter the correct information in the TKR Spreadsheet Template. The specifications contain detailed information on each column that you will need to submit for the measure including column order, definitions, and examples. Summary of Changes Plan for Transition to PROMIS Global-10 PROMIS-10 is replacing the EQ5D-5L patient reported outcome tool for assessing pre-operative and postoperative quality of life. This change is effective for patients undergoing a procedure as of 1/1/2015. For patients who had a pre-op assessment with EQ5D and a post-op assessment with PROMIS Global-10, conversion of values will occur within the MNCM data portal. Please refer to Appendix A and the Data and Field Specifications for more details; Appendix F for measure development work group rationale. EQ5D Versions No Longer Apply In previous submission measurement periods there was a reference to version of EQ5D (3 response version = 3L and new five response version = 5L). Complete transition to the EQ5D-5L was to occur by 1/1/2013, so all references to the old 3L versions were removed in addition to the fields for identifying version used. Optional Fields for OKS Individual Values Submitting the individual values of the OKS tool was provided as an option to groups; however only the summary OKS score is required for submission and measure calculation. Very few groups are utilizing this option; therefore optional fields will be removed from the data submission file. Column Field Name Notes Excel Format Example A Clinic ID Enter the MNCM Clinic ID for every patient/ row submitted. MNCM assigns the clinic ID at the time of registration. Use the MNCM ID listed in the MNCM Data Portal. Do not use the Medical Group ID. Blank values will create ERRORs upon submission. Quality Check: Verify ID in each cell matches the MNCM ID in the portal. Text 905 Page 19

20 Column Field Name Notes Excel Format Example B Patient ID Enter a unique patient ID that will identify each patient. Options: Text Keep a crosswalk between the patient ID and the patient name and DOB to help clinic staff locate the record for the validation audit. Enter clinic-assigned ID (e.g., MRN, account number). Do NOT enter social security numbers. Blank values will create an ERROR upon submission. Quality Check: Verify that patient s procedure was not duplicated. However, if a duplicate is found, make sure that the patient has undergone two separate TKR procedures during the measurement period. C Patient Date of Birth Enter the patient s date of birth. Patient must be 18 years or older on the date of procedure. Date (mm/dd/yyyy) 05/08/1985 BLANK or dates after 01/01/1995 will create a file ERROR upon submission. Quality Check: Verify each date of birth is within the accepted range D Patient Gender Enter the patient s gender: Female = F; Male = M; Unknown = U Blank values will create an ERROR upon submission. Quality Check: Verify each cell has one of the accepted codes. Text F E Patient Zip Code Enter the patient s five-digit zip code of primary residence at the most recent encounter on or prior to 03/31/2015. If EMR query extracts a nine-digit number, submit the nine-digit number (the portal will remove the last four digits automatically). Blank values will create an ERROR upon submission. Quality Check: Verify the zip code is five digits and that each cell has data. Text Page 20

21 Column Field Name Notes Excel Format Example F G H I Race/Ethnicity1 Race/Ethnicity2 Race/Ethnicity3 Race/Ethnicity4 Please refer to a separate document entitled 2015 REL Data Field Specifications and Codes for these field specifications. This document can be found via the link above, under the RESOURCES Tab in the data portal under the Race/Ethnicity/Language Data (REL) section, or on MNCM.org under Submitting Data > Training & Guidance > Data Collection. Number 1 J K L M N O P Race/Ethnicity5 Country of Origin Code Country of Origin Other Primary Language Code Primary Language Other Surgeon NPI Number Provider Specialty Code These are optional fields. 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 under Data Collection. Quality Checks: Verify each cell has one of the accepted codes. Blank cells (if there is no data is available) are acceptable Enter the ten-digit NPI number of the surgeon who performed the total knee replacement procedure. BLANK values will create an ERROR upon submission. Quality Check: Verify each cell has data. Enter the provider code of the specialty of the surgeon performing the total knee replacement: 22 = Orthopedic Medicine/ Surgery Blank values will create an ERROR upon submission. Quality check: Verify each cell has an accepted code. Page 21 Number 2 Text Number 1 Text Country A Language B Text Number 22

22 Column Field Name Notes Excel Format Example Q Insurance Please refer to a separate document entitled 2015 Insurance Coverage Data Field Number 1 Coverage Code Specifications and Codes for these field specifications. This document can be R Insurance found via the link above, under the RESOURCES Tab in the data portal under the Text CIGNA Coverage Insurance Coverage Field Specs & Codes for DDS section., or on MNCM.org Other under Submitting Data > Training & Guidance > Data Collection. S Description Insurance Plan Member ID This should be the patient s most recent insurance on or prior to 03/31/2015 Quality Checks: Verify each cell has an accepted code and that all 99 codes have a name entered in Column R. Verify SSN are NOT submitted. T Diagnosis Code Enter the patient s primary diagnosis. This diagnosis should indicate the condition for which the knee replacement is occurring. This diagnosis can be obtained from either the pre-operative visit with the orthopedic surgeon or from the dictated operative note. If the pre-operative and intraoperative diagnosis differs, use the intraoperative diagnosis. Blank values will create an ERROR upon submission. Quality Check: Verify each cell has data. Text FBZXV1234 Text Page 22

23 Column Field Name Notes Excel Format Example U Procedure Type Enter the type of total knee replacement for this procedure date: Number 1 1 = Primary Total Knee Replacement 2 = Revision Total Knee Replacement This field will be used to stratify results by primary or revision patients. May use the primary CPT codes to determine the status of primary or revision: Primary Total Knee Replacement: Arthroplasty, knee hinge prosthesis Arthroplasty, knee condyle and plateau, medial OR lateral compartment Arthroplasty, knee condyle and plateau, medial AND lateral compartment with or without patellar resurfacing (total knee arthroplasty) Revision Total Knee Replacement: Revision of total knee arthroplasty, with or without allograft, 1 component Revision of total knee arthroplasty, with or without allograft, femoral and entire tibial component Blank values will create an ERROR upon submission. Quality Check: Verify each cell has an accepted code. V Height Inches Enter the patient s height in inches. One decimal place is allowed to reflect onehalf inch (e.g., 62.5). Rounding up or down as appropriate to the next whole number is acceptable as well, depends on system capability. Must be collected (measured) in a clinical setting and not a patient reported value. Field is used with weight to calculate the patient s BMI. Leave BLANK if height is not available. Quality Check: If data is entered, verify it is a whole number or one decimal point is used. If decimals are used, verify only one decimal place is used. Number One decimal or may round up or down to whole inches 62.5 Page 23

24 Column Field Name Notes Excel Format Example W Weight Pounds Enter the patient s pre-operative weight in pounds. Do not use decimals. Round Number 130 up or down to the nearest pound. Use the most recent weight within six months whole number prior to the procedure; do not include weights that are > 6 months prior to the (round up or procedure. Must be collected (measured) in a clinical setting and not a patient down) reported value. Field is used with height to calculate the patient s BMI. Leave BLANK if weight is not available. Quality Check: If data is entered, verify a whole number is used. Verify no decimal places are used. X Diabetes Enter a code to indicate if the patient has either Type 1 or Type 2 diabetes? 1 = Yes 0 = No Leave BLANK if unknown. Any of the following sources can be used to identify the diagnosis of diabetes: patient s problem list, documentation in the patient s record (progress note) or ICD-9 codes from an EMR or practice. ICD-9 codes for diabetes are in the range of Quality Check: Verify each cell has an accepted code if data is entered. Y Tobacco Status Enter the patient s pre-operative tobacco status. Tobacco includes any amount of cigarettes, cigars, pipes, or chew. Do NOT count e-cigarettes as tobacco products. 1 = Tobacco Free (patient does not use tobacco) 2 = No Documentation 3 = Current Tobacco User Leave BLANK if unknown/not submitting data. Quality Check: Verify each cell has an accepted code if data is entered. Number 0 Number 1 Page 24

25 Column Field Name Notes Excel Format Example Z Date of Procedure Enter the date of the total knee replacement procedure. Blank values or values outside the measurement period will create ERRORs upon submission. Quality Check: Verify all dates are between 01/01/2013 to 12/31/2013. Date (mm/dd/yyyy) 11/10/2013 AA Facility ID Enter the code for the hospital where the total knee replacement procedure was performed. Please refer to Table 1 and Table 2 in Appendix B. This data element can be used for reporting outcome information by hospital. Please search the tables thoroughly for the code as facility names may not match exactly as you expect. Blank values will create ERRORs upon submission. Quality Check: Verify that each cell has an accepted code. If 999 is entered into cell, verify text is entered in Column AB for this row. AB Facility Other Description If the facility (and subsequent code) where the procedure was performed is not listed in Tables 1 or 2 in Appendix B and the Facility ID = 999 Other, enter the description of the location where the total knee replacement was performed. Quality Check: Verify that in each row that has text entered in this cell if 999 is entered into Column AA. AC Facility Type Enter the type of facility in which the total knee replacement procedure was performed: 1 = Hospital 2 = Free Standing Outpatient Ambulatory Surgery Center Blank values will create ERRORs upon submission. Quality check: Verify that each cell has an accepted code. Text 41 Text Number 1 Elk Ridge Surgery Center Page 25

26 Column Field Name Notes Excel Format Example For all Oxford Knee Score (OKS) Fields including Pre-operative and Post-operative; refer to Appendix A for more information about how to implement and score the OKS. The OKS functional status assessment is submitted as the summary score only. Valid range of summary scores is 0 to 48; 48 reflects the best possible knee function If the patient selects more than one response for a single question; select the worst (most severe) response and use to calculate the summary score. Don t assume that the higher numeric value is the worst score for this tool; the tool is scaled with numeric ratings where a higher number is better function and the lower number is worse function AD Preop OKS Date Target = Pre-op assessment within 3 months prior to procedure Enter the date in which the pre-operative OKS was completed by the patient. If more than one preoperative OKS was obtained, use the OKS that is the most recent and prior to the procedure. Leave BLANK if a pre-operative OKS evaluation was not obtained. Quality Check: Verify dates are valid. Date (mm/dd/yyyy) 10/27/2013 AE Preop OKS Score Enter the total pre-operative OKS score numeric score. Only include scores for patients who have answered ALL questions, do not submit scores for partially completed tools. If the patient selects more than one response for a single question; select the worst (most severe) response and use to calculate the summary score. Note: the worst response in the OKS tool is a lower numeric value. Leave BLANK if a pre-operative OKS evaluation was not obtained or if any preoperative OKS question was skipped. Quality Check: Verify that the score is between 0 and 48. Number; 23 Page 26

27 Column Field Name Notes Excel Format Example For All EQ5D-5L Fields: If a pre-operative or post-operative EQ5D-5L assessment was not obtained, the patient record should still be submitted; however, the EQ5D- 5L fields should be left blank. If a patient skips one of the five domain questions, submit values for the questions that the patient did answer. Values have merit individually for understanding the patient population and use for potential risk adjustment. However, the health index score can only be calculated when all five questions are completed. If a patient selects more than one response to a question, submit response as a blank (no value). Do not attempt to select a value (unlike OKS). According to EuroQol, the tool developer, two responses to a question invalidates the tool. For EQ5D Health State field - If there is a discrepancy between the where the patient as placed the X and the number the patient has written in the box, use the numeric value written in the box. If a pre-operative or post-operative EQ5D-5L evaluation was obtained, but an answer was skipped, leave that answer blank. The MNCM Data Portal will evaluate all incoming responses, and if a valid response is submitted for each of the five domain questions, will calculate the EQ5D-5L health index. Please refer to the MNCM Data Portal RESOURCES tab after selecting Total Knee Replacement from the drop-down menu and Appendix A in this guide for more details. Plan for Transition EQ5D-5L to PROMIS Global-10: Measuring the patient s quality of life following the procedure is transitioning to a new tool- PROMIS Global-10 for patients with procedure dates starting 1/1/2015. For patients who had a pre-op assessment with EQ5D and a post-op assessment with PROMIS Global-10, conversion of values will occur within the MNCM data portal. Please refer to Appendix A for more information. AF Preop EQ5D Date Target = Pre-op assessment within 3 months prior to procedure Enter the date in which the pre-operative EQ5D-5L was completed by the patient. If more than one preoperative EQ5D-5L was obtained, use the EQ5D-5L that is the most recent and prior to the procedure. Leave BLANK if a pre-operative EQ5D-5L evaluation was not obtained. Quality Check: Verify dates are valid. Date (mm/dd/yyyy) 10/27/2011 Page 27

28 Column Field Name Notes Excel Format Example AG Preop EQ5D 2 Mobility Enter the value of the patient s pre-operative response to the EQ5D-5L Mobility Statement. 1 = I have no problems in walking. 2 = I have slight problems walking. 3 = I have moderate problems walking. 4 = I have severe problems walking. 5 = I am unable to walk. Number; AH Preop EQ5D Self Care Enter the value of the patient s pre-operative response to the EQ5D-5L Self Care Statement. 1 = I have no problems with washing or dressing myself. 2 = I have slight problems washing or dressing myself. 3 = I have moderate problems washing or dressing myself. 4 = I have severe problems washing or dressing myself. 5 = I am unable to wash or dress myself. Number; 2 Page 28

29 Column Field Name Notes Excel Format Example AI Preop EQ5D Enter the value of the patient s pre-operative response to the EQ5D-5L Usual Number; 3 Usual Activities Activities Statement. 1 = I have no problems doing my usual activities. 2 = I have slight problems doing my usual activities. 3 = I have moderate problems doing my usual activities. 4 = I have severe problems doing my usual activities. 5 = I am unable to do my usual activities. AJ Preop EQ5D Pain Enter the value of the patient s pre-operative response to the EQ5D-5L Pain/Discomfort Statement. 1 = I have no pain or discomfort. 2 = I have slight pain or discomfort. 3 = I have moderate pain or discomfort. 4 = I have severe pain or discomfort. 5 = I have extreme pain or discomfort. Number; 2 Page 29

30 Column Field Name Notes Excel Format Example AK Preop EQ5D Enter the value of the patient s pre-operative response to the EQ5D-5L Number; 1 Anxiety Anxiety/Depression Statement. Depression 1 = I am not anxious or depressed. 2 = I am slightly anxious or depressed. 3 = I am moderately anxious or depressed. 4 = I am severely anxious or depressed. 5 = I am extremely anxious or depressed. AL Preop EQ5D Health State Enter the value of the patient s pre-operative response to the EQ5D-5L Best Imaginable Health Statement. This value corresponds with a scale that the patient points to, ranging from 0 (worst imaginable health status) to 100 (best imaginable health status) If there is a discrepancy between the where the patient as placed the X and the number the patient has written in the box, use the numeric value written in the box. Leave BLANK if a pre-operative answer was not obtained. Quality Check: If data is entered, verify it is a whole number between 0 to 100. Number; 76 Page 30

31 Column Field Name Notes Excel Format Example For All PROMIS Global-10 Fields: The PROMIS Global 10 tool is going to be used for ALL patients undergoing total knee replacement procedures starting 01/01/2015. It will replace the EQ5D-5L. If your medical group has the ability to collect and report PROMIS-10 for patients who underwent procedures prior to 12/31/2013, you can submit the PROMIS-10 data. If the patient selects more than one response for a PROMIS-10 question; submit a blank for the value for that question. After your medical group has implemented the PROMIS-10 tool, there is no need to use the EQ5D for follow-up assessments of patients who were assessed pre-operatively with the EQ5D prior to 01/01/2015. The MNCM Data Portal will convert PROMIS-10 values to an EQ5D health index score for all patients with a date of procedure before 01/01/2015. This will allow for consistency of measurement within each calendar year based measurement period. AM Preop PGH Date Target = Preoperative assessment within three months prior to procedure Enter the date when the pre-operative PROMIS Global Health 10 was completed by the patient. If more than one pre-operative PROMIS Global Health 10 was obtained, use the most recent and prior to the procedure. Data Portal logic will use month functionality (calendar date math) to determine if the pre-operative PROMIS Global Health 10 date was three months prior to the date of procedure. Leave BLANK if a pre-operative PROMIS Global Health 10 evaluation was not obtained. Quality Check: Verify dates are valid. Date (mm/dd/yyyy) 05/28/2013 AN Preop PGH 1 Health Enter the value of the patient s pre-operative response to the PROMIS Global Health 10 question regarding general health rating. 1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent Page 31 Number, 3

32 Column Field Name Notes Excel Format Example AO Preop PGH 2 Enter the value of the patient s pre-operative response to the PROMIS Global 3 Quality Health 10 question regarding general quality of life. 1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent Number, AP Preop PGH 3 Physical Enter the value of the patient s pre-operative response to the PROMIS Global Health 10 question regarding general physical health. 1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent Number, 3 Page 32

33 Column Field Name Notes Excel Format Example AQ Preop PGH 4 Enter the value of the patient s pre-operative response to the PROMIS Global 3 Mental Health 10 question regarding general mental health. 1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent Number, AR Preop PGH 5 Satis Social Enter the value of the patient s pre-operative response to the PROMIS Global Health 10 question regarding general satisfaction with social activities and relationships. 1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent Number, 3 Page 33

34 Column Field Name Notes Excel Format Example AS Preop PGH 9 Soc Enter the value of the patient s pre-operative response to the PROMIS Global 3 Activities Health 10 question regarding ability to carry out social activities and roles. 1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent Number, AT Preop PGH 6 Phys Activities Enter the value of the patient s pre-operative response to the PROMIS Global Health 10 question regarding ability to carry out physical activities. 1 = Not at all 2 = A little 3 = Moderately 4 = Mostly 5 = Completely Number, 3 Page 34

35 Column Field Name Notes Excel Format Example AU Preop PGH 10 Enter the value of the patient s pre-operative response to the PROMIS Global 3 Emotional Health 10 question regarding emotional problems in the past 7 days. 1 = Always 2 = Often 3 = Sometimes 4 = Rarely 5 = Never Number, AV Preop PGH 8 Fatigue Enter the value of the patient s pre-operative response to the PROMIS Global Health 10 question regarding fatigue on average in the past 7 days. 1 = Very severe 2 = Severe 3 = Moderate 4 = Mild 5 = None Number, 3 AW Preop PGH 7 Pain Enter the value of the patient s pre-operative response to the PROMIS Global Health 10 question regarding pain rating in the past 7 days using a scale of 0 (No Pain) to 10 (Worst imaginable pain). Number, 3 Page 35

36 Column Field Name Notes Excel Format Example AX 3 Mon Postop Enter the date in which the three month post-operative OKS was completed by Date 2/9/2012 OKS Date the patient. It is acceptable to have three month post-operative OKS within nine Target = Post-op weeks to 20 weeks after the procedure date. (mm/dd/yyyy) assessment within 9 weeks to 20 weeks Leave BLANK if a three month post-operative OKS evaluation was not obtained. Quality Check: Verify dates are valid. after procedure AY 3 Mon Postop OKS Score Enter the total three month post-operative OKS numeric score. Only include scores for patients who have answered ALL questions, do not submit scores for partially completed tools. If the patient selects more than one response for a single question; select the worst (most severe) response and use to calculate the summary score. Note: the worst response in the OKS tool is a lower numeric value. Leave BLANK if a three month post-operative OKS evaluation was not obtained or if any three month post-operative OKS question was skipped. Quality Check: Verify that the score is between 0 and 48. Number; 31 AZ 3 Mon Postop EQ5D Date Target = Post-op assessment within 9 weeks to 20 weeks after procedure Enter the date in which the three month post-operative EQ5D was completed by the patient. It is acceptable to have three month post-operative EQ5D within nine weeks to 20 weeks post procedure date. Include the date (any date) the three month post-operative EQ5D was administered; the data portal will evaluate the OKS date as compared to the date of the procedure. Scores outside of the nine week to 20 week timeframe will not be included. Leave BLANK if a three month post-operative EQ5D evaluation was not obtained. Quality Check: Verify dates are valid. Date (mm/dd/yyyy) 2/9/2012 Page 36

37 Column Field Name Notes Excel Format Example BA 3 Mon Postop Enter the value of the patient s three month post-operative response to the Number; 2 EQ5D Mobility EQ5D-5L Mobility Statement. 1 = I have no problems in walking. 2 = I have slight problems walking. 3 = I have moderate problems walking. 4 = I have severe problems walking. 5 = I am unable to walk. BB 3 Mon Postop EQ5D Self Care Enter the value of the patient s three month post-operative response to the EQ5D-5L Self Care Statement. 1 = I have no problems with washing or dressing myself. 2 = I have slight problems washing or dressing myself. 3 = I have moderate problems washing or dressing myself. 4 = I have severe problems washing or dressing myself. 5 = I am unable to wash or dress myself. Number; 1 Page 37

38 Column Field Name Notes Excel Format Example BC 3 Mon Postop Enter the value of the patient s three month post-operative response to the Number; 2 EQ5D Usual EQ5D-5L Usual Activities Statement. Activities 1 = I have no problems doing my usual activities. 2 = I have slight problems doing my usual activities. 3 = I have moderate problems doing my usual activities. 4 = I have severe problems doing my usual activities. 5 = I am unable to do my usual activities. BD 3 Mon Postop EQ5D Pain Enter the value of the patient s three month post-operative response to the EQ5D-5L Pain/Discomfort Statement. 1 = I have no pain or discomfort. 2 = I have slight pain or discomfort. 3 = I have moderate pain or discomfort. 4 = I have severe pain or discomfort. 5 = I have extreme pain or discomfort. Number; 2 Page 38

39 Column Field Name Notes Excel Format Example BE 3 Mon Postop Enter the value of the patient s three month post-operative response to the Number; 1 EQ5D Anxiety EQ5D-5L Anxiety/Depression Statement. Depression 1 = I am not anxious or depressed. 2 = I am slightly anxious or depressed. 3 = I am moderately anxious or depressed. 4 = I am severely anxious or depressed. 5 = I am extremely anxious or depressed. BF 3 Mon Postop EQ5D Health State Enter the value of the patient s three month post-operative response to the EQ5D-5L Best Imaginable Health Statement. This value corresponds with a scale that the patient points to, ranging from 0 (worst imaginable health status) to 100 (best imaginable health status) If there is a discrepancy between the where the patient as placed the X and the number the patient has written in the box, use the numeric value written in the box. Leave BLANK if a three month post-operative EQ5D Health State answer was not obtained. Quality Check: If data is entered, verify it is a whole number between 0 to 100. Number; 84 Page 39

40 Column Field Name Notes Excel Format Example BG 3 Mon Postop Date 05/28/2013 PGH Date (mm/dd/yyyy) BH Target = Post-op assessment within 9 weeks to 20 weeks after procedure 3 Mon Postop PGH 1 Health Enter the date when the post-operative PROMIS Global Health 10 was completed by the patient. If more than one post-operative PROMIS Global Health 10 was obtained, use the PROMIS Global Health 10 that is the most recent and prior to 20 weeks after the date of the procedure. Data Portal logic will use a calculation for this time window based on the number of days elapsed since the date of procedure (calendar date math) to determine if the three month post-operative PROMIS Global Health 10 date was between six and 20 weeks after the date of procedure. Leave BLANK if a post-operative PROMIS Global Health 10 was not obtained. Quality Check: Verify dates are valid. Enter the value of the patient s post-operative response to the PROMIS Global Health 10 question regarding general health rating. 1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent Number, 3 Page 40

41 Column Field Name Notes Excel Format Example BI 3 Mon Postop Enter the value of the patient s post-operative response to the PROMIS Global 3 PGH 2 Quality Health 10 question regarding general quality of life. 1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent Number, BJ 3 Mon Postop PGH 3 Physical Enter the value of the patient s post-operative response to the PROMIS Global Health 10 question regarding general physical health. 1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent Number, 3 Page 41

42 Column Field Name Notes Excel Format Example BK 3 Mon Postop Enter the value of the patient s post-operative response to the PROMIS Global 3 PGH 4 Mental Health 10 question regarding general mental health. 1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent Number, BL 3 Mon Postop PGH 5 Satis Social Enter the value of the patient s post-operative response to the PROMIS Global Health 10 question regarding general satisfaction with social activities and relationships. 1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent Number, 3 Page 42

43 Column Field Name Notes Excel Format Example BM 3 Mon Postop PGH 9 Soc Activities Enter the value of the patient s post-operative response to the PROMIS Global Health 10 question regarding ability to carry out social activities and roles. 1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent Number, 3 BN 3 Mon Postop PGH 6 Phys Activities Enter the value of the patient s post-operative response to the PROMIS Global Health 10 question regarding ability to carry out physical activities. 1 = Not at all 2 = A little 3 = Moderately 4 = Mostly 5 = Completely Number, 3 Page 43

44 Column Field Name Notes Excel Format Example BO 3 Mon Postop PGH 10 Emotional Enter the value of the patient s post-operative response to the PROMIS Global Health 10 question regarding emotional problems in the past 7 days. 1 = Always 2 = Often 3 = Sometimes 4 = Rarely 5 = Never Number, 3 BP 3 Mon Postop PGH 8 Fatigue Enter the value of the patient s post-operative response to the PROMIS Global Health 10 question regarding fatigue on average in the past 7 days. 1 = Very severe 2 = Severe 3 = Moderate 4 = Mild 5 = None Number, 3 BQ 3 Mon Postop PGH 7 Pain Enter the value of the patient s post-operative response to the PROMIS Global Health 10 question regarding pain rating in the last 7 days using a scale of 0 (No Pain) to 10 (Worst imaginable pain). Quality Check: Verify each cell has a value between one and 10. Number, 3 Page 44

45 Column Field Name Notes Excel Format Example BR 1 Yr Postop OKS Enter the date in which the one year post-operative OKS was completed by the Date 12/13/2012 Date patient. It is acceptable to have one year post-operative OKS within nine to Target = Post-op fifteen months post procedure date. (mm/dd/yyyy) assessment within 9 to 15 months after procedure Include the date (any date) the one year post-operative OKS was administered: the data portal will evaluate the OKS date as compared to the date of the procedure. Scores outside of 9 to 15 months will not be included the measure calculation. Leave BLANK if a one year post-operative OKS evaluation was not obtained. Quality Check: Verify dates are valid. BS 1 Yr Postop OKS Score Enter the total one year post-operative OKS numeric score. Only include scores for patients who have answered ALL questions, do not submit scores for partially completed tools. If the patient selects more than one response for a single question; select the worst (most severe) response and use to calculate the summary score. Note: the worst response in the OKS tool is a lower numeric value. Leave BLANK if a one year OKS evaluation was not obtained or if any one year OKS question was skipped. Quality Check: Verify that the score is between 0 and 48. Number; 42 Page 45

46 Column Field Name Notes Excel Format Example BT 1 Yr Postop Enter the date in which the one year post-operative EQ5D-5L was completed by Date 12/13/2012 EQ5D Date the patient. It is acceptable to have one year OKS within 9 to 15 months post Target = Post-op procedure date. (mm/dd/yyyy) assessment within 9 to 15 months after procedure Include the date (any date) the one year post-operative EQ5D was administered: the data portal will evaluate the EQ5D-5L date as compared to the date of the procedure. Scores outside of the 9 to 15 months will not be included in the measure calculation. Leave BLANK if a one year post-operative EQ5D-5L evaluation was not obtained. Quality Check: Verify dates are valid. BU 1 Yr Postop EQ5D Mobility Enter the value of the patient s one year post-operative response to the EQ5D-5L Mobility Statement. 1 = I have no problems in walking. 2 = I have slight problems walking. 3 = I have moderate problems walking. 4 = I have severe problems walking. 5 = I am unable to walk. Number; 1 Page 46

47 Column Field Name Notes Excel Format Example BV 1 Yr Postop 1 EQ5D Self Care Enter the value of the patient s one year post-operative response to the EQ5D-5L Self Care Statement. 1 = I have no problems with washing or dressing myself. 2 = I have slight problems washing or dressing myself. 3 = I have moderate problems washing or dressing myself. 4 = I have severe problems washing or dressing myself. 5 = I am unable to wash or dress myself. Number; BW 1 Yr Postop EQ5D Usual Activities Enter the value of the patient s one year post-operative response to the EQ5D-5L Usual Activities Statement. 1 = I have no problems doing my usual activities. 2 = I have slight problems doing my usual activities. 3 = I have moderate problems doing my usual activities. 4 = I have severe problems doing my usual activities. 5 = I am unable to do my usual activities. Number; 1 Page 47

48 Column Field Name Notes Excel Format Example BX 1 Yr Postop Number; 1 EQ5D Pain Enter the value of the patient s one year post-operative response to the EQ5D-5L Pain/Discomfort Statement. 1 = I have no pain or discomfort. 2 = I have slight pain or discomfort. 3 = I have moderate pain or discomfort. 4 = I have severe pain or discomfort. 5 = I have extreme pain or discomfort. BY 1 Yr Postop EQ5D Anxiety Depression Enter the value of the patient s one year post-operative response to the EQ5D-5L Anxiety/Depression Statement. 1 = I am not anxious or depressed. 2 = I am slightly anxious or depressed. 3 = I am moderately anxious or depressed. 4 = I am severely anxious or depressed. 5 = I am extremely anxious or depressed. Number; 1 Page 48

49 Column Field Name Notes Excel Format Example BZ 1 Yr Postop Enter the value of the patient s one year post-operative response to the EQ5D-5L Number; 90 EQ5D Health Best Imaginable Health Statement. State This value corresponds with a scale that the patient points to, ranging from 0 (worst imaginable health status) to 100 (best imaginable health status). If there is a discrepancy between the where the patient as placed the X and the number the patient has written in the box, use the numeric value written in the box. Leave BLANK if a one year post-operative answer was not obtained. Quality Check: If data is entered, verify it is a whole number between 0 to 100. CA 1 Yr Postop PGH Date Target = Post-op assessment within 9 to 15 months after procedure Enter the date when the post-operative PROMIS Global Health 10 was completed by the patient. If more than one post-operative PROMIS Global Health 10 was obtained, use the PROMIS Global Health 10 that is the most recent and within 15 months after the date of procedure. Data Portal logic will use a calculation for this time window based on the number of days elapsed since the date of procedure (calendar date math) to determine if the one year post-operative PROMIS Global Health 10 date was between nine and 15 months after the date of procedure. Leave BLANK if a post-operative PROMIS Global Health 10 was not obtained. Quality Check: Verify dates are valid. Date (mm/dd/yyyy) 05/28/2013 Page 49

50 Column Field Name Notes Excel Format Example CB 1 Yr Postop PGH 3 1 Health CC 1 Yr Postop PGH 2 Quality Enter the value of the patient s post-operative response to the PROMIS Global Health 10 question regarding general health rating. 1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent Enter the value of the patient s post-operative response to the PROMIS Global Health 10 question regarding general quality of life. 1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent Number, Number, 3 Page 50

51 Column Field Name Notes Excel Format Example CD 1 Yr Postop PGH Enter the value of the patient s post-operative response to the PROMIS Global 3 3 Physical Health 10 question regarding general physical health. 1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent Number, CE 1 Yr Postop PGH 4 Mental Enter the value of the patient s post-operative response to the PROMIS Global Health 10 question regarding general mental health. 1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent Number, 3 Page 51

52 Column Field Name Notes Excel Format Example CF 1 Yr Postop PGH 3 5 Satis Social Enter the value of the patient s post-operative response to the PROMIS Global Health 10 question regarding general satisfaction with social activities and relationships. 1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent Number, CG 1 Yr Postop PGH 9 Soc Activities Enter the value of the patient s post-operative response to the PROMIS Global Health 10 question regarding ability to carry out social activities and roles. 1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent Number, 3 Page 52

53 Column Field Name Notes Excel Format Example CH 1 Yr Postop PGH Enter the value of the patient s post-operative response to the PROMIS Global 3 6 Phys Activities Health 10 question regarding ability to carry out physical activities. 1 = Not at all 2 = A little 3 = Moderately 4 = Mostly 5 = Completely Number, CI 1 Yr Postop PGH 10 Emotional Enter the value of the patient s post-operative response to the PROMIS Global Health 10 question regarding emotional problems in the past 7 days. 1 = Always 2 = Often 3 = Sometimes 4 = Rarely 5 = Never Number, 3 Page 53

54 Column Field Name Notes Excel Format Example CJ 1 Yr Postop PGH Enter the value of the patient s post-operative response to the PROMIS Global 3 8 Fatigue Health 10 question regarding fatigue on average in the past 7 days. 1 = Very severe 2 = Severe 3 = Moderate 4 = Mild 5 = None Number, CK 1 Yr Postop PGH 7 Pain Enter the value of the patient s post-operative response to the PROMIS Global Health 10 question regarding pain rating using a scale of 0 (No Pain) to 10 (Worst imaginable pain). Quality Check: Verify each cell has a value between one and 10. Number, 3 Page 54

55 Step 2: Quality Check the Data MNCM recommends completing several internal quality checks of the data prior to submission. Quality checks improve data accuracy, reduce the likelihood of errors, and ensure that the data can be validated upon audit. Quality Check Option 1 Use Excel s AutoFilter feature to complete quality checks of specific data elements in the Excel file. To set the filter and review specific data elements, follow these instructions: 1. Click inside any data cell and activate the AutoFilter by doing the following: a. In Excel 2003, click the Data menu, point to Filter, and then click AutoFilter. b. In Excel 2007 and Excel 2010, click the Data tab and in the Sort & Filter area click Filter. 2. The AutoFilter arrows now appear to the right of each column heading. 3. Click on the arrow of any column to display drop-down boxes and scan for key entry errors and out-ofrange or missing data (e.g., a date of procedure outside the date of procedure range 01/01/2013 to 12/31/2013). Determine if the data needs to be corrected. 4. To display all data again, click on the same drop-down box and select All. 5. Remove the Filter option by doing the following: a. In Excel 2003, click Data, Filter, and AutoFilter again. b. In Excel 2007 and Excel 2010, click the Filter option again in the Sort & Filter area. Example Quality Check: Verify that every patient with an OKS assessment date has an associated OKS Score value entered by clicking the OKS Score drop-down menu to see a list of values and other selections; scroll through the values to verify that the scores entered are valid scores from the tool which include a range of zero to forty eight; values above 48 may indicate a math error or typo. Quality Check Option 2 Complete an internal audit of clinical data by reviewing a random sample of records (either 8-10 records) or a full sample (30 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. Quality Check Option 3 Complete the general quality checks outlined below: 1. Conduct the quality checks listed in the Notes column of each data element in the Data Elements and Field Specifications Table on pages Confirm there are no hyphens or zeroes (0s). If the data field is supposed to be blank, do NOT enter hyphens or zero; instead leave it blank. 3. Confirm there are no blank rows at the end of the spreadsheet. Blank rows at the bottom of the Excel file can slow the data submission process. Page 55

56 To check for blank rows, press Ctrl/End at the same time to go to the bottom-most cell in the spreadsheet. Remove any by highlighting the blank rows, right-clicking in the left margin, and selecting Delete. Considerations during Quality Checks If errors are found during quality checks, consider if they are isolated cases or indicative of a larger data collection problem. (e.g., there are no patients with a height listed in Column V (Height Inches) and your clinic consistently measures patient s height). It is important to complete quality checks of the file before submitting data to MNCM. This can help avoid delays in the file submission and ensure submission of the most accurate data. All changes, additions or corrections must be made in the Excel file before submitting data to MNCM. Page 56

57 Section C: Data File Creation Total Knee Replacement 2015 The third stage in the process to calculate performance scores is to create the data file for submission in the MNCM Data Portal. 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. Ensure that all original columns remain in the spreadsheet even if there is no data. Do NOT delete any columns Once these steps are completed, save the Excel template and then save the file as a CSV file, which will be uploaded to the MNCM Data Portal. CSV stands for comma separated values. A CSV file is a common and simple format used to import or transport data between systems or software applications that are not directly related. If at any point in the process it is discovered that corrections to the data are needed, do NOT open the CSV file in Excel. Doing so destroys the formatting and alters the data. Instead, to view or make corrections to the data, open your original Excel file. Then save the changes as 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. 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 or 2007 users). If multiple tabs were created in the Excel spreadsheet, select the correct tab and proceed with the following steps. 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). 3. Select Move or Copy Sheet To book (new book) this is a dropdown selection. 4. Click Create Copy. 5. In this new book, click File, Save As. 2. Right-click the tab of the spreadsheet you wish to save (near the bottom of the screen). 3. Select Move or Copy Sheet To book (new book) this is a drop-down selection. 4. Select Create a Copy and click OK. 5. In this new book, click the Office Button (upper left-hand corner of screen); Select Save As. 2. Right-click the tab of the spreadsheet you wish to save (near the bottom of the screen). 3. Select Move or Copy Sheet To book (new book) this is a drop-down selection. 4. Select Create a Copy and click OK. 5. In this new book, click the File tab (upper left-hand corner of screen); Select Save As. 6. Select the folder and file name of your choice. 7. At the very bottom, you will see Save as type; choose from the drop-down menu, CSV (comma delimited). 8. 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. 9. 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. Page 57

58 Section D: Data File Submission The fourth stage in the process to calculate performance scores is to submit the data file to MNCM through the MNCM Data Portal. Data File Transfer Selection Beginning 2014, the Minnesota Department of Health (MDH) is requesting the receipt of patient level data for the uses described below. MDH has assured us that your organization is permitted to disclose this patient level data to MDH under applicable law (including Minnesota law and HIPAA) because it will be used by MDH only for public health activities, health oversight activities, or other activities required or authorized by state or federal law. Please indicate your selection on the MNCM Data Portal to indicate if you choose to have MNCM share patient-level data with MDH. A list of the data elements for each measure that will be shared with MDH is available in the MNCM Data Portal by going to the RESOURCES tab and selecting Minnesota Statewide Quality Reporting and Measurement System from the drop-down menu. MDH will use patient level data to: Validate quality measure results Publicly report medical group results Research risk adjustment methodologies Design and evaluate public health interventions Research and analyze health disparities MDH will not use patient level data to pursue investigatory or regulatory activities. When you are ready to make this selection: 1. Click on the Data Files Transfer step on the HOME tab of the MNCM Data Portal under the Total Knee Replacement 2015 Report (2013 Dates of Procedure) measure heading. 2. Choose one of the two data sharing options: YES My organization agrees to have MNCM share our patient-level data with MDH for specified measures. NO My organization does not agree to have MNCM share our patient-level data with MDH. 3. Click Save. Page 58

59 Data Submission Total Knee Replacement 2015 Go to HOME in the MNCM Data Portal and scroll down to the Total Knee Replacement 2015 Report (2013 Dates of Procedure) measure. Click on Data Submission and follow the steps below. Step 1: Enter Denominator Medical groups can manually enter denominator counts and information or enter the information into an Excel sheet and upload the Excel file. Use the instructions below. Manual Entry To manually enter denominator counts and information, enter the following information for each clinic row. Once the information is entered, click on Save and Continue. Method Used for Data Collection: Select one of the methods from the drop-down box o EMR: All data pulled via query o EMR: Some data looked up manually o EMR: All data looked up manually o Manual: Paper records only o Manual: EMR and paper record 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 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. Preferred Language and Country of Birth: Allowing patient to self-report these demographic data. Not Reporting: Check this box if a clinic is not reporting for this cycle of data collection. o o Please be advised that MNCM s policy is that ALL clinic sites within a medical group submit their data through the DDS process. Likewise, this is a condition of participation for Minnesota Bridges to Excellence (BTE) and other pay-for-performance programs. Provide a reason the clinic is not reporting. For example: The clinic has no patients meeting eligibility criteria. Excel Upload To enter the denominator counts and information into an Excel sheet that will then be uploaded to the MNCM Data Portal, use the following instructions. 1. Click on Download the Denominator Worksheet. The clinic names will be displayed in Column A and the clinic IDs will be displayed in Column B. 2. Complete the worksheet by entering the following information for each clinic: Method Used for Data Collection (Column C): Enter the appropriate code for each clinic ID. 1 = EMR: All data pulled via query Page 59

60 2 = Manual: Paper records only 3 = Manual: EMR and paper record 4 = EMR: Some data looked up manually 5 = EMR: All data looked up manually REL Data Collection (Columns D G): Indicate if collection of race, Hispanic ethnicity, preferred language and country of birth occurred using best practice methods. Best practice methods include: o o Race and Hispanic Ethnicity: Allowing patient to self-report race AND not using a multi-racial category AND system allows the collection and reporting of more than one race. Preferred Language and Country of Birth: Allowing patient to self-report these demographic data. For each clinic ID, indicate if best practices are used by using the following codes and instructions: 1 = Yes, we follow the best practice 0 = No, we do not follow the best practice o Column D: Enter the appropriate code (1 or 0) to indicate if patients are allowed to self-report race and Hispanic Ethnicity o Column E: Enter the appropriate code (1 or 0) to indicate if clinic is NOT using a multi-racial category AND system allows the collection and reporting of more than one race o Column F: Enter the appropriate code (1 or 0) to indicate if patients are allowed to self-report preferred language o Column G: Enter the appropriate code (1 or 0) to indicate if patients are allowed to self-report race and Hispanic Ethnicity Not Reporting (Column H): Indicate if a clinic is not reporting for this cycle of data collection by entering the following code. Leave as 0 if a clinic is reporting data. 1 = Clinic is NOT reporting o Be advised that MNCM s policy requires ALL clinic sites within a medical group submit their data through the DDS process. Likewise, that is a condition of participation for Minnesota Bridges to Excellence (BTE and other pay-forperformance programs. Reason not reporting (Column I): Provide a reason the clinic is not reporting. (e.g., the clinic has no patients meeting eligibility criteria.) 3. Save the Excel file as a CSV file (see page 57 for more information). Click Browse to search and find the CSV file and then click Submit File. Page 60

61 Step 2: Review & Save Total Knee Replacement 2015 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. To view errors and warnings, please click View Errors & Warnings. 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 19-54) to review the required data for each column. 1. Errors: These are hard stops in the portal (i.e., DOB is out-of-range). Corrections must be made to any errors and a new file uploaded to the MNCM data portal. 2. Warnings: These are possible incorrect data (i.e., LDL is 1000). Review the warnings and decide if corrections are needed. If corrections to the data file are necessary, proceed to instructions below. If corrections are not necessary, click Continue to Step 4. Data file corrections If errors are found, the data file must be corrected and resubmitted in the MNCM Data Portal. Refer to the Data Elements and Field Specifications table (pages ) to review the required data for each column. To start from Step 3: If corrections are only needed to the data file, make corrections in the original Excel file and save the corrected file with a new name. Then save as a new CSV file to upload. Do NOT make corrections in the original CSV file, as it will destroy the format and alter the data. Go back to the MNCM Data Portal submission page and click Re-Upload Data (csv) File. 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. In this case, all number entries and a new file upload will be necessary. Once the CSV File has been re-uploaded without any errors or warnings needing correction, click Continue to Step 4. Step 4: Review & Submit Review and check each box of the Pre-Submission Quality Checklist and contact MNCM if you have any questions regarding the Pre-Submission Quality Checklist. Please review the quality checks for each item listed in the Data Elements and Field Specifications table on pages If you need to resubmit the data file only, click Re-Upload Data (CSV) File. If you need to resubmit the denominator counts and the data file, click Clear & Start Over at the bottom of the page. If you have checked all the boxes, click Continue. Page 61

62 The page will be refreshed. You will be asked to review the current measurement period s preliminary rates for each clinic compared to the prior period s data submission 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 only, click Re-Upload Data (CSV) File. If you need to resubmit the denominator counts and the data file, click Clear & Start Over at the bottom of the page. Once you have entered an explanation, click Save Notes. The page will update to save the notes. Please review this information and determine if the file is ready to submit to MNCM. You can click Save as Draft if you need to review the information in more detailed prior to submitting the file to MNCM. To access your information, you can click on Data Submission under the Total Knee Replacement 2015 Report (2013 Dates of Procedure) section on the HOME tab. When the data file is ready to submit to MNCM: Click Submit Data to MNCM. Step 5: Done! The data file has been successfully submitted. MNCM will send an that the data has been received. You can download the data by clicking Download Data near the top of the data comparison section to see which patients were optimal (1) and which were not (0) by viewing the additional columns on the right-hand side of the document. Page 62

63 Section E: Data Validation After data is submitted, MNCM completes key validation steps to identify potential data errors. If errors are identified, the medical group must make corrections to the data and resubmit before MNCM approves the data. MNCM completes data validation in three steps: data quality checks, the validation audit, and the two-week medical group review. MNCM completes data quality checks of the demographic data, patient population and outcome results. Validation audits verify the submitted data matches source data in the medical record. And, prior to approving final results, medical groups are given an opportunity to review preliminary statewide results during what is called the two-week medical group review. Each step is critical to the validation process and ensures results are accurate and comparable. Preparing for the Validation Audit All medical groups are subject to a validation audit. If your medical group is selected for audit, MNCM will contact you to schedule the audit. MNCM will provide list of sample records that will be audited. Medical groups are expected to prepare for the audit as follows: The medical group or clinic site representative must be available to participate in the entire audit process. o For data that resides in an electronic record, the audit will be conducted via a HIPAA secure, online meeting service; the medical group or clinic representative will need to retrieve and display the selected records and screens necessary to complete the validation. o For data that resides in a paper record, the audit will take place onsite. Patient names or other personal information may be blinded. MNCM will verify the record is correct using the date of birth submitted. 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 date of birth, as necessary. o Data collection forms and other notes describing where various data elements were located in the patient record. o List of patients that were excluded, if applicable. MNCM Validation Process MNCM utilizes the NCQA (National Committee for Quality Assurance) 8 and 30 process for validation audits. MNCM randomly selects 33 records from each applicable clinic site for validation. At most, 30 records for each clinic site will be reviewed. The additional three records are oversamples to ensure 30 records will be available on the day of the review. The MNCM auditor reviews records 1 to 8 in the sample to verify whether the submitted data matches the source data in the medical record. Page 63

64 If all of the first eight records reviewed have no errors, the compliance rate is 100%, and the clinic site is determined to be in high compliance. The MNCM auditor may determine no further record review is necessary. The MNCM auditor communicates results to MNCM staff. If the auditor identifies one or more records with errors, he/she will continue auditing records 9 to 30 and a compliance rate is calculated (e.g., 27/30 records compliant, 90%). If the compliance rate is less than 90%, the MNCM auditor will communicate the results with MNCM staff who will contact the medical group to discuss a resubmission plan. Two-Week Medical Group Review The two-week medical group review is the official opportunity to review and comment on the statewide results before they are approved. Each medical group is responsible for reviewing its own results, investigating any concerns, and submitting evidence to MNCM if a change in results is requested. In that event, MNCM staff will review the evidence and determine whether the data will be included in the statewide results. After Validation Audit Once MNCM validation processes are complete, MNCM will approve the data in the MNCM Data Portal. An automatic will be generated and sent to the medical group s data contact notifying them that the data is approved. After all statewide results are approved, MNCM may publish medical group level results on MN HealthScores ( You can also find the results on the MNCM Data Portal on the Results tab. Medical groups should maintain data submission files and other documents related to their data submission for two years. Page 64

65 Total Knee Replacement: Functional Status and Quality of Life Outcome Measures 2015 Direct Data Submission Dates of Procedure 01/01/2013 to 12/31/2013 Appendices Page 65

66 Appendices Appendix A: Patient Reported Outcome (PRO) Tools The most important step in measuring the change in functional status and quality of life for patients is to implement the administration of the PRO tools into the clinic s processes and work flows. PRO tools need to be integrated into the pre-operative evaluation and post-operative follow-up at three months and one year. There are two PRO tools used to calculate the outcomes for the patient: Oxford Knee Score a knee specific functional status assessment tool EQ-5D-5L, a quality of life assessment tool. [Transition to PROMIS Global Health 10] Additional Information about PRO Tools Ideally tools are completed by the patient at the time of the pre-operative and post-operative visits; however office visits are not required for tool completion. Any provider or office staff may administer the pre and postoperative assessment tools. PRO Patient Reported Outcome Tools- Modes of acceptable administration Administration Mode OKS EQ5D PROMIS-10 In person/during visit Acceptable Acceptable Acceptable Via mail Acceptable Acceptable Acceptable Via telephone Not Acceptable* Not Acceptable* Acceptable Administer electronically ** Acceptable + Prohibited Acceptable *Tools have not been validated for phone administration and/ or visual analog components would be difficult to replicate by phone interview. **When administering electronically, the tool must be kept intact including content, order and scoring. Electronic examples: , patient portal, ipad/tablet, patient kiosk. + Review and approval of electronic adaptation of the OKS created by a medical group is required by Isis Innovation, Inc., the tool copyright holder.guidelines for epro adaptation of this tool can be found on the Resources tab in the Data Portal. Other Activities OKS EQ5D PROMIS-10 Store results in EMR Acceptable Acceptable Acceptable Must seek approval for other uses* Yes Yes Yes * examples: research, publication, use of tool beyond measure population, etc. NOTE: All patients who meet the initial patient population criteria must be included in the data submission file, whether or not they completed the Patient Reported Outcome tools. Page 66

67 Appendices Oxford Knee Score (OKS) This is a patient completed survey consisting of twelve structured questions asking the patient to describe the impact of their knee function in the following areas: level of pain, self-care, getting in and out of a car, length of time able to walk, sitting, kneeling, night pain, interference with usual work, limping and ability to climb or descend stairs. Scale of 0 to 48 where 48 is the best possible knee-related functional status. More information can be found at: The OKS functional status assessment is submitted as the summary score only. The valid range of summary scores is 0 to 48; 48 reflect the best possible knee function. Only submit scores when the patient has answered all twelve questions, do not submit a score for a patient when the tool is only partially completed. Incomplete tools make the functional status appear worse than it really is as a lower number indicates increased severity of symptoms. If the patient selects more than one response for a single question; select the worst (most severe) response and use to calculate the summary score. Don t assume that the higher numeric value is the worst score for this tool; the tool is scaled with numeric ratings where a higher number is better function and the lower number is worse function References Dawson J, Fitzpatrick R, Murray D, Carr A. Questionnaire on the perceptions of patients about total knee replacement. J Bone Joint Surg Br Jan;80(1):63-9 Murray D.W., Fitzpatrick R., Rogers K., Pandit H., Beard D., Carr A.J., Dawson J. The use of the Oxford hip and knee scores. J. Bone Joint Surg. [Br] 2007;89-B: http://isis-innovation.com/ Permissions The OKS tool was developed by Professor Ray Fitzpatrick and Dr. Jill Dawson at Oxford University. The OKS document in use in the clinics must specify the following copyright language: Isis Innovation Limited, All rights reserved. Oxford Knee Score English for the United States. Permission was granted to MNCM for the use of the OKS in individual clinical practice for the purposes of participating in MNCM s data submission and reporting of functional status outcome measures. If any group or clinic plans to use results from the OKS tool for other purposes (i.e., research study and publication), additional licensure will need to be obtained from ISIS Innovation Ltd to avoid copyright infringement. The OKS tool is located on the data portal under the Resources Tab/ Total Knee Replacement Resources/ Functional Status Tools at Page 67

68 EQ-5D-5L Total Knee Replacement 2015 Appendices This is a tool developed by EuroQol and is a standardized instrument for use as a measure of health related quality of life. The EQ-5D-5L assessment of current health state consisting of six questions asking the patient to describe in general (not related to their low back function) mobility, self-care, usual activities, pain/discomfort and anxiety/depression and a visual analog 100 point scale where patient rates current health state today. Applicable to a wide range of health conditions and treatments, it provides a simple descriptive profile and a single index value for health status. The EQ-5D-5L is designed for self-completion by respondents and is ideally suited for use in postal surveys, in clinics and face-to-face interviews. It is cognitively simple, taking only a few minutes to complete. For more information on the EQ-5D visit the website at While relatively simple for the patient to take the test, the actual scoring of the tool is quite complicated and lends itself well to applying a program to calculate the index score. For this reason, we are asking groups to submit the corresponding number to each of the patient s response for the first five questions. If a patient selects more than one response to a question, submit response as a blank (no value). Do not attempt to select a value (unlike ODI and VAS). According to EuroQol, the tool developer, two responses to a question invalidates the tool. If there is a discrepancy between the where the patient as placed the X and the number the patient has written in the box, use the numeric value written in the box. Plan for Transition EQ5D-5L to PROMIS Global-10: Measuring the patient s quality of life following the procedure is transitioning to a new tool- PROMIS Global-10 for patients with procedure dates starting 1/1/2015. For patients who had a pre-op assessment with EQ5D and a post-op assessment with PROMIS Global-10, conversion of values will occur within the MNCM data portal. Please refer to measure development work group details in Appendix F. References The EuroQol Group (1990). EuroQol-a new facility for the measurement of health-related quality of life. Health Policy 16(3): Brooks R (1996). EuroQol: the current state of play. Health Policy 37(1): Permission Permission was granted to MNCM for the use of the EQ5D-5L in individual clinical practice for the purposes of participating in the state-wide quality reporting and improvement effort. If any medical group or practice plan to use results from the EQ5D-5L tool for other purposes (i.e., research study and publication), additional licensure will need to be obtained from EuroQol to avoid copyright infringement. Page 68

69 Appendices PROMIS Global Health 10 PROMIS Global Health 10 a patient completed assessment of health related quality of life consisting of 10 structured questions reported on two subscales general physical health and general mental health. NIH sponsored tool publicly available, free of charge, with multiple modes of administration available. Recommended by the measure development work group to replace the EQ5D-5L in 2015 and conversion of PROMIS 10 to EQ5D-5L supports a transition plan without the loss of ability to measure health related quality of life in the interim. For more information, access the PROMIS website: Given the need to convert the PROMIS Global Health-10 score to the EQ5D-5L Index, medical groups must submit the corresponding number to each of the patient s response for all questions. If the patient selects more than one response for a PROMIS-10 question; submit a blank for the value for that question. References Hays, R. D., Bjorner, J. B., Revicki, D. A., Spritzer, K. L., & Cella, D. (2009). Development of physical and mental health summary scores from the patient-reported outcomes measurement information system (PROMIS) global items. Quality of Life Research, 18(7), Permissions Permission was granted to MNCM for the use of the PROMIS Global Health- 10 in individual clinical practice for the purposes of participating in the state-wide quality reporting and improvement effort. If any medical group or practice plan to use results from the PROMIS-10 tool for other purposes or other populations (i.e., research study and publication), it is recommended that an additional user agreement with PROMIS Health Organization be obtained by the medical group that outlines its planned use. Request form for instruments can be obtained at Page 69

70 Appendix B: Facility Codes Total Knee Replacement 2015 Appendices The tables below only include facilities within the state of Minnesota. The tables are not all inclusive. If the hospital or freestanding outpatient surgical center where the procedure was performed does not have an ID number assigned below, enter a code of 999 for Other and complete the free text field Facility Other Description. Table 3: Hospital Facility Codes 51 Abbott Northwestern Hospital 205 Albany Area Hospital and Medical Center 206 Appleton Area Health Services 172 Avera Marshall Regional Medical Center 104 Bigfork Valley Hospital 211 Buffalo Hospital 213 Cambridge Medical Center 276 CentraCare Health - Long Prairie 281 CentraCare Health - Melrose 294 CentraCare Health - Monticello 149 CentraCare Health - Sauk Centre 38 Children's Hospitals and Clinics of Minnesota - MPLS 27 Children's Hospitals and Clinics of Minnesota - STP 217 Chippewa County-Montevideo Hospital 224 Community Memorial Hospital 230 Cook County North Shore Hospital 229 Cook Hospital & C&NC 231 Cuyuna Regional Medical Center 117 District One Hospital 234 Douglas County Hospital 237 Ely-Bloomenson Community Hospital 203 Essentia Health - Ada 225 Essentia Health - Deer River 290 Essentia Health - Duluth 246 Essentia Health Fosston 261 Essentia Health - Graceville 175 Essentia Health - Northern Pines 124 Essentia Health - Sandstone 142 Essentia Health - St. Joseph's Medical Center 167 Essentia Health - Virginia 147 Essentia Health St. Mary's - Detroit Lakes 148 Essentia Health St. Mary's Medical Center 186 Fairview Lakes Health Services 241 Fairview Northland Medical Center 44 Fairview Ridges Hospital 41 Fairview Southdale Hospital 267 FirstLight Health System 42 Gillette Children's Specialty Healthcare 250 Glacial Ridge Health System 251 Glencoe Regional Health Services 264 Grand Itasca Clinic and Hospital 253 Granite Falls Municipal Hospital & Manor 258 Hendricks Community Hospital Association 22 Hennepin County Medical Center 262 Hutchinson Health 266 Johnson Memorial Health Services 269 Kittson Memorial Healthcare Center 271 Lake Region Healthcare 272 Lake View Memorial Hospital 3 Lakeview Hospital 159 LakeWood Health Center 161 Lakewood Health System 121 LifeCare Medical Center 277 Madelia Community Hospital 278 Madison Hospital 279 Mahnomen Health Center 32 Maple Grove Hospital 100 Mayo Clinic Health System - Albert Lea 150 Mayo Clinic Health System - Austin 215 Mayo Clinic Health System in Cannon Falls 239 Mayo Clinic Health System in Fairmont 270 Mayo Clinic Health System in Lake City 561 Mayo Clinic Health System in Mankato 114 Mayo Clinic Health System in New Prague 138 Mayo Clinic Health System in Red Wing 130 Mayo Clinic Health System in Springfield 171 Mayo Clinic Health System in St. James 170 Mayo Clinic Health System in Waseca 120 Mayo Clinic Rochester Hospital, Methodist Campus 145 Mayo Clinic Rochester Hospital, Saint Mary s Campus 280 Meeker Memorial Hospital 2 Mercy Hospital 283 Mercy Hospital 228 Mille Lacs Health System 24003F Minneapolis VA Medical Center 292 Minnesota Valley Health Center 299 Murray County Medical Center 127 New Ulm Medical Center 30 North Memorial Medical Center 169 North Valley Health Center 105 Northfield Hospital 107 Olmsted Medical Center 108 Ortonville Area Health Services 257 Owatonna Hospital 26 Park Nicollet Methodist Hospital 110 Paynesville Area Health Care System 112 Perham Health 33 Phillips Eye Institute 113 Pipestone County Medical Center 254 Prairie Ridge Hospital and Health Services 245 Rainy Lake Medical Center 285 Range Regional Health Services 116 RC Hospital & Clinics Red Lake Hospital 296 Redwood Area Hospital 12 Regina Medical Center 11 Regions Hospital 118 Rice Memorial Hospital 6 Ridgeview Medical Center 222 River's Edge Hospital & Clinic 119 RiverView Health 204 Riverwood Healthcare Center 133 Saint Elizabeth's Medical Center 219 Sanford Bagley Medical Center 102 Sanford Bemidji Medical Center 214 Sanford Canby Medical Center 265 Sanford Jackson Medical Center 221 Sanford Luverne Medical Center 106 Sanford Thief River Falls Medical Center 156 Sanford Tracy Medical Center 235 Sanford Westbrook Medical Center 174 Sanford Wheaton Medical Center 177 Sanford Worthington Medical Center 8 Shriners Hospitals for Children 207 Sibley Medical Center 129 Sleepy Eye Medical Center 367 St. Cloud Hospital 24002F St. Cloud VA Medical Center 134 St. Francis Healthcare Campus Page 70

71 7 St. Francis Regional Medical Center 136 St. Gabriel's Hospital 21 St. John's Hospital 140 St. Joseph's Area Health Services Inc. 13 St. Joseph's Hospital 143 St. Luke's Hospital 152 Stevens Community Medical Center Total Knee Replacement 2015 Appendices 153 Swift County-Benson Hospital 157 Tri-County Health Care 201 Tyler Healthcare Center/Avera 565 U.S. PHS Indian Hospital- Cass Lake 567 U.S. PHS Indian Hospital- Red Lake 52 United Hospital 162 United Hospital District 4 Unity Hospital 19 University of Minnesota Medical Center, Fairview 176 Windom Area Hospital 227 Winona Health Services 14 Woodwinds Health Campus Table 4: Freestanding Outpatient Surgical Centers 64 Allina Health - Abbott Northwestern WestHealth 53 Allina Health - University Avenue Surgery Center 18 Brainerd Lakes Surgery Center 50 CDI Twin Cities ASC 11 Centennial Lakes Surgery Center 31 CentraCare Surgery Center, Saint Cloud 5 Central Minnesota Surgical Center 61 Chaska Plaza Surgery Center, LLC 21 Children's - Minnetonka 49 Chu Surgery Center 9 Crossroads Surgery Center 17 Crosstown Surgery Center 19 Edina Surgery Center, Inc 52 Fairview Maple Grove Surgery Center 54 Family Surgery Center LLC 69 Greenway Surgery Center 3 High Pointe Surgery Center 22 Institute for Low Back and Neck Care, Special Procedures 7 Lakewood Surgery Center 13 Landmark Surgery Center 10 Mankato Surgery Center 43 Maplewood Surgery Center 48 Midsota Surgical Suites 47 Midwest Surgery Center 42 Minnesota Orthopaedic Surgery Center LLC 41 Minnesota Surgery Center, Ltd - Edina 40 Minnesota Surgery Center, Ltd - Maple Grove 38 Minnesota Valley Surgery Center, LLC 4 North Memorial Ambulatory Surgery Center at Maple Grove 29 North Metro Surgery Center 67 Pain Centers of Minnesota-Mankato 39 Pavilion Surgery Center, LLC 62 Sanford Health Detroit Lakes Clinic Same Day Surgery Center 26 South Central Surgical Center 23 Southwest Minnesota Surgical Center, Inc. 32 Southwest Surgical Center dba Orthopaedic Institute Surgery Center 15 Saint Cloud Surgical Center 30 TRIA Orthopaedic Center, LLC 6 Willmar Surgery Center 14 Woodbury Ambulatory Surgery Center Page 71

72 Appendices Appendix C: Additional Measures The following is a list of measures that will be calculated based on the data file submission of patients meeting inclusion criteria, no additional calculations or submissions are required from the medical groups. MNCM Measure Additional Measures Total Knee Replacement (TKR) Direct Data Submission Measures The measure development work group developed a suite of measures for patients undergoing total knee replacement, consisting of outcome and process measures. Outcome measures will provide information about functional status and quality of life improvements following TKR procedures. The three month postoperative functional status measures were selected to demonstrate potential variation in provider technique and postoperative rehabilitation (important to providers), whereas the measure at one year reflects the functional status that can be achieved (important to patients) Process measures provide an understanding about a medical group s/ clinic s adoption of the functional status tools. Additional Outcome Measures Include: Average postoperative functional status improvement at three months post operatively for patients undergoing TKR as measured by the Oxford Knee Score tool. Average postoperative quality of life improvement at three months post operatively for patients undergoing TKR as measured by the EQ-5D tool. Additional Process Measures Include: The percentage of TKR patients who have a preop, three month and one year assessment of functional status with the Oxford Knee Score and EQ-5D quality of life score. Number of TKR procedures performed during the measurement period Number and % of TKR patients administered a preop Oxford Knee Score (within 3 months of proc) Number and % of TKR patients administered a preop EQ-5D (within 3 months of procedure) Number and % of TKR patients administered a three month postoperative Oxford Knee Score Number and % of TKR patients administered a one year postoperative Oxford Knee Score Number and % of TKR patients administered a three month postoperative EQ-5D Number and % of TKR patients administered a one year postoperative EQ-5D Number and % of TKR patients administered both a pre-operative and one year postoperative Oxford Knee Score Three months is defined as any time between 9 weeks to 20 weeks postop. One year is defined as any time between 9 to 15 months postop. Page 72

73 Appendices Appendix D: MNCM Data Portal Registration Registration must be completed prior to data submission and is completed once a year. Registration instructions can be found under RESOURCES on the MNCM Data Portal Contact MNCM at support@mncm.org if you did not register. If your medical group opened or closed clinics after the 2015 Clinic and Provider Registration ended in February 2015, contact MNCM to discuss updating registration and clinic information. 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. Contact support@mncm.org to discuss submitting this data. Page 73

74 Appendices Appendix E: Resources to Help You Get Started MNCM offers a selection of resources and tools to identify your population, collect data, and get started in the data submission process: To access the resources and tools for Total Knee Replacement Functional Status and Quality of Life Outcome Measure 2015 Report (2013 Dates of Procedure) section, login to the MNCM Data Portal at and click on RESOURCES. Select Cycle B - Total Knee Replacement from the dropdown menu. The Cycle B - Total Knee Replacement screen contains Total Knee Replacement Data Collection Guide, Data Colleciton Tools and Frequently Asked Questions. The documents you will need to download include: Total Knee Replacement 2015 Data Collection Guide TKR 2015 Spreadsheet Template TKR 2015 Pre-Submission Data Certification Template Optional: TKR 2015 Data Collection Form this form is a patient-level form that is most useful for medical groups and clinics using paper records. Page 74