DATA COLLECTION GUIDE - 2018 Optimal Asthma Control

DATA COLLECTION GUIDE - 2018 Optimal Asthma Control

DATA COLLECTION GUIDE - 2018 Optimal Asthma Control

DATA COLLECTION GUIDE 2018 Optimal Asthma Control 2018 Asthma Education and Self-Management (01/01/2017 to 12/31/2017 Dates of Service) Data Submission: 01/08/2018 to 02/15/2018

DATA COLLECTION GUIDE - 2018 Optimal Asthma Control

Helpline: 612-746-4522 | E-mail: support@mncm.org | MNCM Data Portal: https://data.mncm.org/login © MN Community Measurement, 2017. All rights reserved. Table of Contents Preface . . i Summary of Changes . ii A. Measure Specification Changes from Previous Year . ii B. Field Specification Changes from Previous Year . ii C. Other Changes from Previous Year . ii D. Changes from Draft to Final .

ii Measure Specifications . iii Measure Logic / Flow Charts . vii Process and Timeline Overview . ix Data Submission Resources . x Section I: Agreements and Pre-Submission Data Certification . . 1 A. Business Associate Agreement . . 1 B. Direct Data Submission Terms and Conditions . . 1 C. Data File Transfer Selection . . 2 D. Pre-Submission Data Certification . . 3 Section II: Data Collection . . 4 A. Eligible Population Identification . . 4 Total Population (recommended . . 5 Sample Population . . 5 Patient Attribution . . 5 B. Data Collection . . 6 Data Elements and Field Specifications .

. 7 C. Data Quality Checks . . 18 Section III: Data Submission . . 19 A. Data File Creation . . 19 B. Data Submission . . 20 Section IV: Data Validation . . 25 Appendices . . 27 Appendix A: About Direct Data Submission . . 27 Appendix B: About MN Community Measurement . . 29 Appendix C: Patient Reported Outcome (PRO) Tools . . 30 Appendix D: Sampling Methods . . 32 Appendix E: Glossary of Terms . . 34

2018 Optimal Asthma Control 2018 Asthma Education and Self-Management Helpline: 612-746-4522 | E-mail: support@mncm.org | MNCM Data Portal: https://data.mncm.org/login © MN Community Measurement, 2017. All rights reserved. i Preface Dear Data Submitters, Attached is our 2018 Optimal Asthma Control / 2018 Asthma Education and Self-Management Data Collection Guide. We greatly appreciate your medical group or clinic contributing data on quality, patient outcomes and patient experience. We know your contribution is vital to MN Community Measurement’s ability to achieve our mission to accelerate the improvement of health by publicly reporting health care information.

We value your involvement and want to support your success as well. We provide resources, tools and reports that your medical group or clinic can use for quality improvement. The following resources can be found on our corporate website, MNCM.org: • Public reports including the Health Care Quality Report, Heath Equity of Care Report, Health Care Disparities Report and Total Cost of Care Report • Patient education and engagement resources • Provider tools and resources • Monthly Q & A session details • Educational webinars throughout the year • Health Trackers Additionally, these resources can be found on the secure MNCM Data Portal: • Detailed reports and charts of clinical measure results • Charts of specific clinical measure results segmented by race, Hispanic ethnicity, preferred language and country of origin (REL) for medical groups following best practices • Patient Experience of Care Survey results at the domain and question-level Finally, on MNHealthScores.org, you can see public-facing results of all of our measures for clinics, medical groups or hospitals.

As this is our consumer-focused site, it has less detail than is available in our reports and on the Data Portal.

MNCM is committed to working with our multi-stakeholder committees to champion the highest value measures that will make the most impact in our community, while balancing burden on organizations that supply the data. As performance improves, we have processes in place to ensure the appropriate retirement of measures to minimize burden. Thank you again for your important role in our work. If you have questions, feel free to contact us at 612-746-4522 or support@mncm.org. Anne Snowden, MPH, CPHQ Director, Performance Measurement, Validation & Reporting

2018 Optimal Asthma Control 2018 Asthma Education and Self-Management Summary of Changes Helpline: 612-746-4522 | E-mail: support@mncm.org | MNCM Data Portal: https://data.mncm.org/login © MN Community Measurement, 2017.

All rights reserved. ii Summary of Changes A. Measure Specification Changes from Previous Year 1. Change of measurement period to calendar year. 2. Clarifying statement added to Diagnosis criteria. See Measure Specifications for further detail. B. Field Specification Changes from Previous Year NONE C. Other Changes from Previous Year 1. Changes to Process and Timeline Overview (Preface). 2. Clarification of eligible population identification requirements (Flow Charts 1 and 2 and Section II-A).

D. Changes from Draft to Final 1. Clarifying language added to definition of Urgent Care Clinics (Glossary).

2018 Optimal Asthma Control 2018 Asthma Education and Self-Management Measure Specifications Helpline: 612-746-4522 | E-mail: support@mncm.org | MNCM Data Portal: https://data.mncm.org/login © MN Community Measurement, 2017. All rights reserved. iii Measure Specifications Summary of Changes • Change of measurement period to calendar year. • Clarifying statement added to Diagnosis criteria. Optimal Asthma Control Description The percentage of pediatric (5-17 years of age) and adult (18-50 years of age) patients who had a diagnosis of asthma and whose asthma was optimally controlled during the measurement period as defined by achieving BOTH of the following: • Asthma well-controlled as defined by the most recent asthma control tool result available during the measurement period • Patient not at elevated risk of exacerbation as defined by less than two emergency department visits and/or hospitalizations due to asthma in the last 12 months Separate rates are reported for each age group.

Measurement Period January 1, 2017 through December 31, 2017 Eligible Population Eligible Specialties Family Medicine, Internal Medicine, Pediatrics, Allergy/Immunology, Pulmonology Eligible Providers Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Advanced Practice Registered Nurses (APRN) Ages 5 years or older at the start of the measurement period AND less than 51 years at the end of the measurement period Diagnosis Patient had a diagnosis of asthma (Asthma Value Set) with any contact during the current or prior measurement period OR had asthma (Asthma Value Set) present on an active problem list at any time during the measurement period.

Both contacts AND the active problem list must be queried for diagnosis (Asthma Value Set). Event At least one established patient office visit (Established Pt Asthma Value Set) performed or supervised by an eligible provider in an eligible specialty for any reason during the measurement period Denominator The eligible population

2018 Optimal Asthma Control 2018 Asthma Education and Self-Management Measure Specifications Helpline: 612-746-4522 | E-mail: support@mncm.org | MNCM Data Portal: https://data.mncm.org/login © MN Community Measurement, 2017. All rights reserved.

iv Numerator The number of patients in the denominator whose asthma was optimally controlled during the measurement period as defined by achieving BOTH of the following: • Asthma well-controlled as defined by the most recent asthma control tool result during the measurement period: • Asthma Control Test (ACT) greater than or equal to 20 (patients 12 years of age and older) • Childhood Asthma Control Test (C-ACT) greater than or equal to 20 (patients 11 years of age and younger) • Asthma Control Questionnaire (ACQ) less than or equal to 0.75 (patients 17 years of age and older) • Asthma Therapy Assessment Questionnaire (ATAQ) equal to 0 – Pediatric (5 to 17 years of age) or Adult (18 years of age and older).

• Patient not at elevated risk of exacerbation as defined by less than two patient reported emergency department visits and/or hospitalizations due to asthma in the last 12 months Required Exclusions The following exclusions must be applied to the eligible population: • Patient had a diagnosis of cystic fibrosis, COPD, emphysema or acute respiratory failure (Obstructive Lung and Respiratory Failure Value Set) Allowable Exclusions The following exclusions are allowed to be applied to the eligible population: • Patient was a permanent nursing home resident at any time during the measurement period • Patient was in hospice or receiving palliative care at any time during the measurement period • Patient died prior to the end of the measurement period • Documentation that diagnosis was coded in error • Patient had only urgent care visits during the measurement period Measure Scoring Rate/Proportion Results are always stratified by age: • Optimal Asthma Control, Children (5-17 years of age) • Optimal Asthma Control, Adults (18-50 years of age) Interpretation of Score Higher score indicates better quality Measure Type Outcome, All-or-none Patient Level Composite

2018 Optimal Asthma Control 2018 Asthma Education and Self-Management Measure Specifications Helpline: 612-746-4522 | E-mail: support@mncm.org | MNCM Data Portal: https://data.mncm.org/login © MN Community Measurement, 2017. All rights reserved. v Asthma Education and Self-Management Description The percentage of pediatric (5-17 years of age) and adult (18-50 years of age) patients who had a diagnosis of asthma, have been educated about their condition, and have a written asthma self-management plan. Measurement Period January 1, 2017 through December 31, 2017 Eligible Population Eligible Specialties Family Medicine, Internal Medicine, Pediatrics, Allergy/Immunology, Pulmonology Eligible Providers Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Advanced Practice Registered Nurses (APRN) Ages 5 years or older at the start of the measurement period AND less than 51 years at the end of the measurement period Diagnosis Patient had a diagnosis of asthma (Asthma Value Set) with any contact during the current or prior measurement period OR had asthma (Asthma Value Set) present on an active problem list at any time during the measurement period.

Both contacts AND the active problem list must be queried for diagnosis. Event At least one established patient office visit (Established Pt Asthma Value Set) performed or supervised by an eligible provider in an eligible specialty for any reason during the measurement period Denominator The eligible population Numerator The number of patients in the denominator who have been educated about their asthma and self-management of the condition and also have a written asthma management plan present [created or reviewed and revised within the measurement period (01/01/2017 to 12/31/2017)]: Patient has a written asthma management plan in the chart with the following documented: • Plan contains information on medication doses and purposes of these medications.

• Plan contains information on how to recognize and what to do during an exacerbation. • Plan contains information on the patient’s triggers.

2018 Optimal Asthma Control 2018 Asthma Education and Self-Management Measure Specifications Helpline: 612-746-4522 | E-mail: support@mncm.org | MNCM Data Portal: https://data.mncm.org/login © MN Community Measurement, 2017. All rights reserved. vi Required Exclusions The following exclusions must be applied to the eligible population: • Patient had a diagnosis of cystic fibrosis, COPD, emphysema or acute respiratory failure (Obstructive Lung and Respiratory Failure Value Set) Allowable Exclusions The following exclusions are allowed to be applied to the eligible population: • Patient was a permanent nursing home resident at any time during the measurement period • Patient was in hospice or receiving palliative care at any time during the measurement period • Patient died prior to the end of the measurement period • Documentation that diagnosis was coded in error • Patient had only urgent care visits during the measurement period Measure Scoring Rate/Proportion Results are always stratified by age: • Asthma Education and Self-Management, Children (5-17 years of age) • Asthma Education and Self-Management, Adults (18-50 years of age) Interpretation of Score Higher score indicates better quality Measure Type Process

2018 Optimal Asthma Control 2018 Asthma Education and Self-Management Measure Specifications Helpline: 612-746-4522 | E-mail: support@mncm.org | MNCM Data Portal: https://data.mncm.org/login © MN Community Measurement, 2017. All rights reserved. vii Measure Logic / Flow Charts Flow Chart 1: Optimal Asthma Control Measure Flow Chart Is the patient’s DOB between 01/01/1967 and 01/01/2012? Did thepatienthavea diagnosis of asthma (Asthma Value Set) with any contactduring the current or prior measurementperiod (01/01/2016 to12/31/2017)? Does the patient have one of the following scores during the measurement period?: Asthma Control Test (ACT) score of 20 or above (taken from most recent Asthma Control Test on file) – only applicable for patients 12 and older ---OR--- Childhood Asthma Control Test (C-ACT) score of 20 or above (taken from most recent C-ACT on file) – only applicable for patients 11 and younger ---OR--- Asthma Control Questionnaire (ACQ) score of 0.75 or lower (taken from most recent ACQon file) – only applicable for patients 17 and older ---OR--- Asthma Therapy Assessment Questionnaire (ATAQ) score of 0 (taken from most recent ATAQ) – for children, adolescents, and adults Has thepatient reported a total number of emergency department visits and hospitalizations in thepast 12 months dueto asthma less than 2? PATIENT NOT INCLUDED IN NUMERATOR PATIENT INCLUDED IN NUMERATOR 2018 Optimal Asthma Control Measure Flow Chart No No Did the patient have at least one established patient officevisit (Established Pt Asthma Value Set) performed or supervised by an eligible provider in an eligible specialty for any reasonduring the measurementperiod (01/01/2017 to12/31/2017)? No PATIENT NOT INCLUDED IN MEASURE PATIENT INCLUDED IN DENOMINATOR Yes Yes Yes No No Yes No Did thepatienthavea diagnosis of asthma (Asthma Value Set) present on an activeproblem list at any time during the measurement period (01/01/2017 to 12/31/2017)?

Yes Yes

2018 Optimal Asthma Control 2018 Asthma Education and Self-Management Measure Specifications Helpline: 612-746-4522 | E-mail: support@mncm.org | MNCM Data Portal: https://data.mncm.org/login © MN Community Measurement, 2017. All rights reserved. viii Flow Chart 2: Asthma Education and Self-Management Measure Flow Chart Does the patient have a written asthma management plan in the medical record that includes ALL following components? 1. Information on medication doses and purpose; 2. Information on how to recognize and what to do during an exacerbation; AND 3.

Information on patient’s triggers. PATIENT NOT INCLUDED IN NUMERATOR PATIENT INCLUDED IN NUMERATOR 2018 Asthma Education and Self-Management Measure Flow Chart PATIENT INCLUDED IN DENOMINATOR Yes Yes No Was the written asthma management plan created or reviewed and revised during themeasurement period (01/01/2017 to 12/31/2017)?

Yes No Is the patient’s DOB between 01/01/1967 and 01/01/2012? Did thepatienthavea diagnosis of asthma (Asthma Value Set) with any contactduring the current or prior measurementperiod (01/01/2016 to12/31/2017)? No No Did the patient have at least one established patient officevisit (Established Pt Asthma Value Set) performed or supervised by an eligible provider in an eligible specialty for any reasonduring the measurementperiod (01/01/2017 to12/31/2017)? No PATIENT NOT INCLUDED IN MEASURE Yes No Did thepatienthavea diagnosis of asthma (Asthma Value Set) present on an activeproblem list at any time during the measurement period (01/01/2017 to 12/31/2017)?

Yes Yes