MEPRS Management Improvement Group
Wednesday, 29 July 2009
9:00 a.m. – 1:00 p.m.
Attendees:
1
MMIG July 29, 2009 meeting minutes
MEPRS Management Improvement Group
Wednesday, 29 July 2009
9:00 a.m. – 1:00 p.m.
(* via phone)
Name / Organization / Name / Organization[Name redacted] / TMA MEPRS / [Name redacted] / Army MEPRS
[Name redacted] / AF MEPRS / [Name redacted] / Army MEPRS
[Name redacted] / HA OSM / [Name redacted] / Navy MEPRS (Change Architect)
[Name redacted] / HA OSM / [Name redacted] / Navy MEPRS (Change Architect)
[Name redacted] / TMA MEPRS (Altarum) / [Name redacted] / Navy MEPRS (Change Architect)
[Name redacted] / TMA MEPRS (Altarum) / [Name redacted] / AF MEPRS
[Name redacted] / TMA UBO / [Name redacted] / AF MEPRS
[Name redacted] / TMA MEPRS (Altarum) / [Name redacted] / AF MEPRS
[Name redacted] / TMA MC&FS / [Name redacted] / AF DQMC
[Name redacted] / TMA DHSS (JACER) / [Name redacted] / TMA MEPRS (SRA)
[Name redacted] / TMA DHSS (JACER) / [Name redacted] / TMA MEPRS (SRA)
[Name redacted] / AF MEPRS
I.Chairman’s Call to Order and Opening Remarks
Following attendancethe Chairperson opened the meeting without additional comments. Minutes from the 19 May 2009 meeting have been approved and posted.
II.PatientCentered Medical Home(PCMH)
The representative from the Office of Strategy Management (OSM) gave a presentation on PCHM (PowerPoint attached) and discussed the PCMH with the MMIG to include the concept and impact of PCMH as well as the implications for the MMIG and what role MEPRS plays in making PCMH successful.
He opened by expressing that OSM wants to be sure that they share the vision of the leadership of the Military Health System. It is about changing the philosophy of how the MHS approaches health care which is particularly important today due to national dialogue on universal coverage. The question is “How can we reinvent health care?”
He stated that there will be a R&A meeting on 27 August to:
- Gain approval of policy of PCMH – already approved by Services.
- Establish guidelines – will adopt NCQA standards.
- Discuss outcomes and measures for the PCMHs already in existence.
PCHM incorporates chronic illness care with primary care which is becoming a prominent philosophy in MHS and congress. Because of the increase the MHS will soon will need to measure the costs incurred by the PCMH. This is the “MEPRS piece.”Dr. Dinneen said that there will be Tri-Service "Summit" in early September to gain Service “buy-in.”
He stated that there is one point to remember:PCMH is not tied to a visit – the patient is in control of their healthcare. In use, the number of patient visits has gone way down, and the number of phone calls has gone way up. PCMH facilitates partnerships between patients, MDs, and family. The HA OSM representative also opined that creating a MEPRS code for CM was in a sense, counterproductive to the concept of PCMH, as each patient will have a case management.
The Army representativeexplained that the Army recently hired another group of Case Managers dedicated to specific clinics so the Army MTFs now have three types of Case Managers. Case Managers dedicated to patients in a specific clinic are coded to the B MEPRS code of the clinic. Case Managers who support all MTF inpatients and outpatients, and are part of the MTF core staffing are reported in ELAN. GWOT/WTU Case Managers are reported in FAZ2 since they represent a second Case Manager for all Active Duty soldiers. She further explained that Case Management reporting and processes were coordinated with the Army Case Management Consultant. Any changes to the Case Management reporting would have to be coordinated with the Case Management Consultant. The HA OSM representative replied that he understands, and that is why he wanted to have this dialogue.
Because the OSM briefing slide mentioned possible new MEPRS codes to support the PCMH concept, Army asked for clarification if the PCMHinvolved new buildings, renovations, additional providers, etc. .The HA OSM representativeexplained that at Bethesda,the PCMH concept usedthe existing buildings and providers. The change is more one of philosophy (thinking and approach) than location.
HA OSM shared a specific story of a patient who encountered multiple problems receiving quality care at a Navy site. After telling the story of the problems encountered by the patient, he stated that the AF is leading in providing quality care, with the Navy behind the AF. He stated that the Army is behind the AF and Navy. Army asked what data was used to make these rankings, and requested a copy of the supporting documentation. HA OSM said that he would provide a copy of the supporting documentation to the MMIG.
HA OSM then reviewed Guideposts (milestones) self-grading criteria for facilities that want to become PCMHs. Main point is that the PCMH should improve care.
He then covered what the PCMH Work Group needs from the MMIG:
Since they need to tie costs to a particular place and they need good cost data to track effectiveness: an approved set of codes that can be used for PCMH.
HA OSM gave a summary of his early analysis of 4th level MEPRS codes used to track workload. His recommendations is to eliminate the use of B**P and B**W MEPRS codes which are used primarily by the AF to track workload and not clinics. (Included in attached hand out.)
AF stated that they have permission to get rid of B**P and B**W, but will consolidate them into another code. They need to find out what the risk may be if theycollapse these MEPRS codes used to track workload. The Army had one site using B**P incorrectly to track workload of Clinical Pharmacists rather than a standalone clinic.
HA OSMsaid he will provide the contact info for the PCMH POCs for all three Services.
The MMIG Chairman stated that the group certainly needs to look at funding to make sure that the costs are incorporated into the discussions. He went on to say that the PCMH POCs need to work with the MMIG POCs as well.
HA OSM gave the names of the Service PCMH POCs. Army commented that they have found that some sites have used MEPRS codes BHB (Physical Exam)/BJA (Flight Medicine)to track a type of workload instead of a standalone clinic. Army has already initiated efforts to analyze and identify erroneous MEPRS codes used to track workload instead of standalone clinics.
III.DQMC: Observation
TMA MC&FS Director addressed an issue concerning “single day admissions” and where the data is being entered into EAS. He stated that it may have been a work around for Observation.
The policy (dated 1999) for recording Observation data in FCC B**0 is still in effect. If the Services no longer follow this policy and do not desire to follow it in the future, then they need to change the policy rather than work around it or recommend it be rescinded and submit new policy to supersede the current policy.
He stated that if this turns out to be a MMIG issue (corrupt data), then the MMIG, UBO, and UBU need to meet to work it out.
Army stated that they found that these Observation MEPRS codes caused many errors. The Army had completed an analysis of all Army MEPRS discrepancies, and B**0 MEPRS codes created a large number of discrepancies in MEPRS reporting; i.e., expenses with workload, but no FTEs, etc. She gave examples of ER visits (BIAA) that were changed to Observation Visits (BIA0) when the patient had never left the ER, and there was no actual Observation Unit. She reported that Madiganclinical coders were changing the MEPRS code of the ER visit to reflect an Observation visit. This created an error so ‘bogus’ Nursing Units were created in DG** MEPRS codes to account for the ‘Observation’ of the patient. Then the MEPRS staff had to transfer FTEs out of the ER to the ‘bogus’ Observation Unit to eliminate additional errors in processing.
Armyalso explained that the only site which has complained to Army MEPRS was Madigan, and their complaint was based on the retirement of the Observation medical record. Madigan stated that they had relied on the Observation MEPRS code to identify when an extended medical record should be retired. She explained that Madigan personnel stated their providers were performing one day inpatient admissions since they could no longer identify the Observation visit medical record for retirement. She explained that the Navy has never used Observation MEPRS codes, and Madigan is the only site that has complained about the loss of the Observation Visit, B**0, MEPRS codes. Army also said that they still need to find out why Madigan has a problem, and other MTFs don’t appear to have a problem. She also explained that the Army has not completed an analysis of the inpatient data to verify that Madigan or any other Army site has started performing one day inpatient admissions in FY09 when the Army stopped using Observation Visit MEPRS codes.
TMA MC&FS recommended collaborating with the UBU. The MMIG Chair agreed. He further stated that the MEPRS PO has requested the data from UBU (changes since 2007) and that the MMIG has not issued any guidance to not use B**0.
Navysaid they are looking for documentation on the Navy rescind order. She will forward this to the MMIG once locates.
Army coordinated with PASBA and UBO representatives before deactivating B*80 Observation MEPRS codes. Army explained that the UBO did not have any concerns with the elimination of the Observation MEPRS codes since UBO stated they used the clinical coding to identify the Observation patients for billing. PASBA has stated that there is a TMA PAD regulation on retirement of medical records. A review of this regulation verified that specific 4th level MEPRS codes are not designated for the retirement of medical records in CHCS. AF and Navy had not seen the problem of retiring medical records.
Army votes to create new policy and rescind the current one.
AF said that B**0 and B**5 doesn't sound like something that PCMH would want anyway and agreed with Army.
Navy agreed to rescind current policy and create new one. They added that had already stopped using B**0.
Army added that, as Navy has said, DGA and DGE should be combined. DGA limits requesting MEPRS codes in CHCS, but DGE allows every variation.
The Chair stated that UBO and TMA MEPRS are working with UBU. He also said that his staff (Altarum) will follow-up on moving forward with eliminating B**0, and drafting a memo for guidance.
UBO said that CHCS forces them to admit patients for Observation and herein lies the disconnect.
UBO explained that keeping B**0 on the record shows the biller to pull for manual billing.
IVMEWACS Moment
TMA MEPRS (SRA) started the discussion by stating that there is an e-mail was sent out requesting a response with an explanation on the outliers. Army asked if she wanted the Services to update you on our outliers on the phone, or send their response by e-mail. TMA MEPRS (SRA) replied by asking them to please send e-mails with the follow-up information which can, in turn, be incorporated in to the slides for the MMIG. That way there will be no need to address at the MMIG meetings.
Army still has some outstanding sites that they haven't heard from but will forward when received.
Navy will follow up regarding Pensacola.
AF gave an update concerning the October financial problem: they will hold off having AF fix October until after they have taken care of September (current months get priority) due to the way EAS is handling the money. Theydo have a resolution ready to go out. Once September is processed, they will have October reprocessed immediately. (see slide 11)
AF stated that Luke lost their MEPRS manager and that AF is seeing some impact there that can be attributed to the loss. Kirtland is having personnel and DMHRSi problems as well. He commented on the other sites that were cited that they are looking to get the data corrected in EAS IV, but will not require the sites to retransmit until close of the FY.
AF said that the EAS/WWR discrepancies at McConnell are to breakdown in communications
AF said he would look into the increase to $17M at O'Callahan.
Other issue raised by AF: once outliers are explained, are they still in MEWACS? TMA MEPRS (SRA) confirmed that they are and at this time that cannot be changed. She also reminded them that she is not looking at all the outliers, just the big ones – things that need to be corrected in the system and we can identify and explain the problems. The result is that the Services can't just say it's DMHRSi every month, but once explained, she may be able to go in and change the color even if it's still an outlier. Only outliers that can be corrected, will change in MEWACS – others will just be explained.
V.EAS Updates
TMA DHSS (JACER)explained that because of resource issues, only high-priority SIRs will be addressed, especially those that impact reports. She is working on getting the contract properly funded so that the MMIG approved and prioritized SCRs can be worked. This will not happen until after the new fiscal year begins. There are approximately 200 SIRs that have been prioritized. She selected has selected about 15 of the most critical for the technical team to work on. She will forward this list to the MEPRS team. Mr. Wesley added that Mr. Edwards will be joining the bi-weekly DHSS/MEPRS status updates meetings.
The MMIG Chair expressed his concern with all the “work-arounds” MEPRS personnel are required to complete to get their work done in the EASIV application to make a MEPRS transmission. He is also concerned with all of the caveats that are included in the MADI training because the EASIV Repository SCRs and the SIRs have not been completed. The Chair added that he witnessed this problem when he attended the USAFE MADI class. He asked TMA MEPRS (SRA) to compile list of all the Repository problems. He added that if we could get those things fixed in the system, especially those that can be done quickly, we wouldn't have to explain all the caveats. Army added that MEPRS personnel coders are using work arounds in the EASIV application that take 10 times more time and effort than should be required.
Action Item: TMA MEPRS (SRA) to send list of outstanding SCR and SIR issues to MEPRS team.
VI.EAS Repository Issues
TMA MEPRS (Altarum) reviewed the EAS IV Repository Class Object Issues Matrix that which contained the list of Repository issues that TMA MEPRS (SRA) had provided to the Chair. TMA MEPRS (Altarum) categorized the issues into the ones thatwere part of the existing MMIG issue paper 051001/SIR 004026 for which EAS PO never received approval. For the other issue, TMA MEPRS (Altarum) wrote issues papers and requested that the Services review each issue paper and either concur or non-concur with each issue paper. For issue papers on whichthe Services concur, TMA MEPRS (Altarum) will write SCRs. For those issues on which the Services do not concur, she will schedule a meeting to discuss the issues and alternate solutions.
Action Item: Services to reply to TMA MEPRS (Altarum) regarding concurrence or non-concurrence on issue papers by COB August 5, 2009.
VII.Table Issues Parking Lot
TMA MEPRS (Altarum) referred to the parking lot list of table issues that generated during the Annual EAS IV Table Update meetings. These are issues that the Services wanted to address during the meetings. Since these issues were not critical to the table update process, it was agreed that we would put them on a parking lot list that would be addressed after July 15. TMA MEPRS (Altarum) said that she will be scheduling a meeting with the Table Service POCs to begin addressing these issues.
Action Item: TMA MEPRS (Altarum) to schedule meeting to discuss EAS IV Table Update Parking Lot issues.
VIII.Service Issues
VII.Strategic Plan
TMA MEPRS (Altarum) Project Lead presented an update on the Strategic Plan process (attached brief). He emphasized that Strategic Plannning is a continuous process, not a one-time action. He also covered the key steps including where TMA authors the beginning framework followed by engaging MMIG for implementation. He noted the comments from stakeholders and formulated goals and objectives that were confirmed by the stakeholders. He said that he, and the contract leadership have met with the MMIG Chair twice, will meet with him a third time (more if needed), then brief TMA MC&FS Director, and then brief the Stakeholders. Once we have buy-in and refinement from TMA MC&FS and the stakeholders, the plan will go back to MMIG to implement.