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MICHIGANCAREIMPROVEMENTREGISTRY:DataQualityPrinciples&BestPracticeStrategiesMichiganDepartmentofHealthandHumanServices.MCIROngoingDataQualityImprovementPlan(ver.August31,2015):Section3,DataQualityPrinciples.
MICHIGANCAREIMPROVEMENTREGISTRY:DataQualityPrinciples&BestPracticeStrategiesJune3,2016/Page1of21
DATA QUALITY PRINCIPLE #1
CONSISTENCY The conditions (criteria) for validating data items should be the same regardless of how the data items have been reported into the correct MCIR record.
Example(s): ü Regardless of a data item’s source and the method of data reporting (e.g., direct user
entry, EXT, or HL7 reporting), the data item should go through the same set of data validation checks (conditions/criteria).
Provider Best Practice (BP): The provider is responsible for monitoring patient demographics or other identifiers to ensure an exact match of data reported into the MCIR record.
Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider Best Practice. • EXT and HL7 Information at www.mcir.org • MCIR DQI Business Plan Perform required regional MCIR data analysis or correction, as necessary. Make appropriate referrals, when necessary.
MCIR Resource Materials:
Visit www.mcir.org for appropriate tip sheets and related resources
MICHIGANCAREIMPROVEMENTREGISTRY:DataQualityPrinciples&BestPracticeStrategiesJune3,2016/Page2of21
DATA QUALITY
PRINCIPLE #2
REJECTED DATA
When information is not accepted it still can be held (in some buffer zone) for a further research or rejected outright. When information is rejected by MCIR, the following actions should occur:
• Electronic import logs errors and notifies submitters • HL7 users can generate an Electronic Submission Summary Report (ESSR) • User Interface (UI) displays an error message, offering user opportunity for error
correction Example(s):
ü MCIR Electronic Submission Summary Report (for HL7 users) ü Summary and VIM Transaction Report (for EXT users) ü Doses Administered Report, along with available inventory reports, assist the end
user in finding, correcting and resubmitting data errors. ü UI users receive edit checks verifying information on the screen, before data
submission. Provider Best Practice (BP): The provider should perform quality assurance tests daily and report data issues.
Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider
MCIR Resource Materials:
Visit www.mcir.org for appropriate tip sheets and related resources
MICHIGANCAREIMPROVEMENTREGISTRY:DataQualityPrinciples&BestPracticeStrategiesJune3,2016/Page3of21
Best Practice. • EXT and HL7 Information at www.mcir.org • MCIR DQI Business Plan
Perform required regional MCIR data analysis or correction, as necessary. Make appropriate referrals, when necessary.
MICHIGANCAREIMPROVEMENTREGISTRY:DataQualityPrinciples&BestPracticeStrategiesJune3,2016/Page4of21
DATA QUALITY
PRINCIPLE #3
INTERNAL CONSISTENCY
Characteristics of the vaccination history should not contradict one another. This includes reported data as well as existing MCIR data. (This principle is a basis for all crosscheck validations. This principle covers cross-validations between characteristics of multiple vaccination events that comprise immunization history, as well as cross-validations between characteristics of individual vaccination events. Vaccination history includes demographics, and information on all recorded vaccination events.)
Example(s):
ü Vaccine type should match administration route. Also, vaccine type should be paired with the licensed vaccine manufacturer.
Provider Best Practice (BP):
The provider should report potential data quality issues to MCIR Regional staff for verification.
Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider Best Practice. • #02-04 MDHHS MCIR Policy for Person and
Vaccine Deduplication • #02-05 MDHHS MCIR policy for Record
MCIR Resource Materials:
Visit www.mcir.org for appropriate tip sheets and related resources
MICHIGANCAREIMPROVEMENTREGISTRY:DataQualityPrinciples&BestPracticeStrategiesJune3,2016/Page5of21
Corrections • #06-01 MDHHS MCIR Policy for Site/User
Training and MCIR Training Checklist
Perform required regional MCIR data analysis or correction, as necessary. Make appropriate referrals, when necessary.
MICHIGANCAREIMPROVEMENTREGISTRY:DataQualityPrinciples&BestPracticeStrategiesJune3,2016/Page6of21
DATA QUALITY PRINCIPLE #4
ACCURACY The data recorded in MCIR should match exactly what happens in a clinical encounter, whether or not it is clinically appropriate.
Example(s): ü Recommended for MCIR staff to periodically audit a random sample of incoming data
to verify that it matches clinical records. ü Submitters should periodically audit a random sample of data to verify that it is
correctly documented in MCIR. Provider Best Practice (BP): The provider office administering immunizations shall accurately document doses given under their MCIR site ID
Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider Best Practice. • MCIR DQI Business Plan
Perform required regional MCIR data analysis or correction, as necessary. Make appropriate referrals, when necessary.
MCIR Resource Materials:
Visit www.mcir.org for appropriate tip sheets and related resources
MICHIGANCAREIMPROVEMENTREGISTRY:DataQualityPrinciples&BestPracticeStrategiesJune3,2016/Page7of21
Provider Best Practice (BP):
The provider site should maintain a MCIR vaccine inventory for the purpose of accountability and accurate documentation of administration.
Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide for appropriate Regional MCIR procedures, as it relates to the Provider Best Practice. • #06-01 MDHHS MCIR Policy for Site/User
Training and MCIR Training Checklist
Perform required regional MCIR data analysis or correction, as necessary. Make appropriate referrals, when necessary.
MCIR Resource Materials:
Visit www.mcir.org for appropriate tip sheets and related resources
Provider Best Practice (BP):
Use exact antigen/vaccine information when documenting administered or historical immunizations when available (e.g., Hib PRP-OMP; Unspecified vaccine types like Hib or NOS are less desirable)
Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider Best Practice. • #02-04 MDHHS MCIR Policy for Person and
MCIR Resource Materials:
Visit www.mcir.org for appropriate tip sheets and related resources
MICHIGANCAREIMPROVEMENTREGISTRY:DataQualityPrinciples&BestPracticeStrategiesJune3,2016/Page8of21
vaccine Deduplication • #02-05 MDHHS MCIR policy for Record
Corrections • MCIR DQI Business Plan
Perform required regional MCIR data analysis or correction, as necessary. Make appropriate referrals, when necessary.
Provider Best Practice (BP):
The provider site should periodically audit MCIR data to ensure an accurate match data recorded in the EHR and/or clinical record(s)
Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider Best Practice.
Perform required regional MCIR data analysis or correction, as necessary. Make appropriate referrals, when necessary.
MCIR Resource Materials:
Visit www.mcir.org for appropriate tip sheets and related resources
MICHIGANCAREIMPROVEMENTREGISTRY:DataQualityPrinciples&BestPracticeStrategiesJune3,2016/Page9of21
DATA QUALITY
PRINCIPLE #5
APPROPRIATE VACCINATION
The vaccinations reported by a provider should be appropriate for the population served at the clinic.
Example(s): ü In a pediatric practice, certain types of vaccines are used in a certain proportion, e.g.,
a certain percentage of DTaP, polio, Hib, and MMR is to be expected.
Provider Best Practice (BP):
The provider should integrate a process(es) into the medical practices’ workflow which requires the review of MCIR data, and the required cross-referencing with EHR/medical record data, prior to determining immunizations to be administered during an office visit.
Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider Best Practice. • #06-01 MDHHS MCIR Policy for Site/User
Training and MCIR Training Checklist
Perform required regional MCIR data analysis or correction, as necessary. Make appropriate referrals, when necessary.
MCIR Resource Materials:
Visit www.mcir.org for appropriate tip sheets and related resources
MICHIGANCAREIMPROVEMENTREGISTRY:DataQualityPrinciples&BestPracticeStrategiesJune3,2016/Page10of21
Provider Best Practice (BP):
The provider office should routinely generate Profile Reports and Dose Administered Reports (DAR) to monitor office immunization assessment levels and ensure individuals seen within the clinic are up-to-date on required vaccinations.
Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider Best Practice. • #06-01 MDHHS MCIR Policy for Site/User
Training and MCIR Training Checklists
Perform required regional MCIR data analysis or correction, as necessary. Make appropriate referrals, when necessary.
MCIR Resource Materials:
Visit www.mcir.org for appropriate tip sheets and related resources
MICHIGANCAREIMPROVEMENTREGISTRY:DataQualityPrinciples&BestPracticeStrategiesJune3,2016/Page11of21
DATA QUALITY
PRINCIPLE #6
VITAL RECORDS
Vital Records is the definitive source for the following MCIR data fields:
• Date of Birth • Date of Death • Adoption • Validation of correct demographic information • Management of duplicate EBC records
Example(s): ü It is possible that an incorrect birth date or death date is transmitted from vital records,
but those are rare occasions. ü End users may flag a person as deceased. ü A feed from vital records also provides an electronic file of official death records to
MCIR. ü Adoption records are managed at the regional level.
Provider Best Practice (BP):
The provider should use the applicable demographics and unique identifiers when searching for the individual’s MCIR record, to ensure an exact record match.
Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider Best Practice. • #01-05 MDHHS MCIR Policy for Processing
MCIR Resource Materials:
Visit www.mcir.org for appropriate tip sheets and related resources
MICHIGANCAREIMPROVEMENTREGISTRY:DataQualityPrinciples&BestPracticeStrategiesJune3,2016/Page12of21
Name Changes and Merges Due to Adoption • #02-03 MDHHS MCIR Policy for Person
Searches • #02-05 MDHHS MCIR Policy for Record
Corrections
Perform required regional MCIR data analysis or correction, as necessary. Make appropriate referrals, when necessary.
Provider Best Practice (BP):
The provider should review, and make the required updates, to an individual’s demographics and Patient Status whenever contact is made with patient information
Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider Best Practice. • #01-05 MDHHS MCIR Policy for Processing
Name Changes and Merges Due to Adoption • #02-05 MDHHS MCIR Policy for Record
Corrections • #02-06 MDHHS MCIR Policy for Patient
Status & Person Does Not Receive Medical Care in Michigan
MCIR Resource Materials:
Visit www.mcir.org for appropriate tip sheets and related resources
MICHIGANCAREIMPROVEMENTREGISTRY:DataQualityPrinciples&BestPracticeStrategiesJune3,2016/Page13of21
Perform required regional MCIR data analysis or correction, as necessary. Make appropriate referrals, when necessary.
MICHIGANCAREIMPROVEMENTREGISTRY:DataQualityPrinciples&BestPracticeStrategiesJune3,2016/Page14of21
DATA QUALITY PRINCIPLE #7
VALIDATION PRIORITY The importance of validating a data item is related to the data item’s significance in clinical decision-making, public health assessments, and research.
Example(s): ü Critical high priority data items are:
o Vaccine Type o Vaccination Encounter Date o Eligibility o Lot number o Manufacturer o Date of Birth • Zip Codes
Provider Best Practice (BP):
The antigen/vaccine information entered by the provider should match exactly the information on the vaccine manufacturer’s box/insert and the MCIR inventory, if/when applicable.
Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider Best Practice. • #06-01 MDHHS MCIR Policy for Site/User
Training and MCIR Training Checklist
Perform required regional MCIR data analysis or
MCIR Resource Materials:
Visit www.mcir.org for appropriate tip sheets and related resources
MICHIGANCAREIMPROVEMENTREGISTRY:DataQualityPrinciples&BestPracticeStrategiesJune3,2016/Page15of21
correction, as necessary. Make appropriate referrals, when necessary.
MICHIGANCAREIMPROVEMENTREGISTRY:DataQualityPrinciples&BestPracticeStrategiesJune3,2016/Page16of21
DATA QUALITY
PRINCIPLE #8
ACIP RECOMMENDATIONS PRINCIPLE
Deviations from ACIP recommendations and U.S. licensure may indicate data quality problems.
Example(s):
ü MCIR does not accept immunization data prior to person DOB. ü If a date of birth is modified on a MCIR record, it could result in some vaccine
encounter dates being documented before the date of birth. ü Immunization assessment issues
Provider Best Practice (BP):
The provider should routinely run recall to identify and notify patients whose MCIR record indicates they are overdue for immunizations
Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider Best Practice. • #06-01 MDHHS MCIR Policy for Site/User
Training and MCIR Training Checklist
Perform required regional MCIR data analysis or correction, as necessary. Make appropriate referrals, when necessary.
MCIR Resource Materials:
Visit www.mcir.org for appropriate tip sheets and related resources
MICHIGANCAREIMPROVEMENTREGISTRY:DataQualityPrinciples&BestPracticeStrategiesJune3,2016/Page17of21
Provider Best Practice (BP):
The provider should routinely utilize MCIR assessment (i.e., vaccination forecasting tool, status screen, batch report, printed record) when assessing an individual for required and recommended vaccine administrations.
Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider Best Practice. • #06-01 MDHHS MCIR Policy for Site/User
Training and MCIR Training Checklist
Perform required regional MCIR data analysis or correction, as necessary. Make appropriate referrals, when necessary.
MCIR Resource Materials:
Visit www.mcir.org for appropriate tip sheets and related resources
MICHIGANCAREIMPROVEMENTREGISTRY:DataQualityPrinciples&BestPracticeStrategiesJune3,2016/Page18of21
DATA QUALITY
PRINCIPLE #9
TIMELINESS
Michigan Department of Health and Human Services requires immunization data to be entered into MCIR within 72 hours of administration for children less than 20 years of age.
Example(s):
ü To be useful for clinical decision support and health policymaking, immunization data should appear in the MCIR soon after the clinical event occurs.
Provider Best Practice (BP):
The provider office should standardize an office practice by which immunizations are recorded into the EHR (or onto a clinical chart) and added to the MCIR timely – within 72 hours (3 business days of administration). Refer to DQ Principle #10.
Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider Best Practice. • #02-01 MDHHS MCIR Policy for Provider
Reporting Compliance • MCIR DQI Business Plan
Perform required regional MCIR data analysis or correction, as necessary. Make appropriate referrals, when necessary.
MCIR Resource Materials:
Visit www.mcir.org for appropriate tip sheets and related resources
MICHIGANCAREIMPROVEMENTREGISTRY:DataQualityPrinciples&BestPracticeStrategiesJune3,2016/Page19of21
DATA QUALITY PRINCIPLE #10
COMPLETENESS The information submitted to MCIR must contain the minimum/mandatory set of data items in order to be accepted by MCIR.
Example(s): ü Required data fields and the minimum/mandatory data sets for necessary MCIR
function and operation ü Relevant data is optional and of value in improving MCIR function. The goal is to
capture all relevant data on persons and their vaccination events. Provider Best Practice (BP): The providers generate, review and correct errors found on EXT submissions and HL7 Electronic Submission Summary Reports (ESSR) daily, at minimum every 72-hours.
Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider Best Practice. • #06-01 MDHHS MCIR Policy for Site/User
Training and MCIR Training Checklist • MCIR DQI Business Plan Perform required regional MCIR data analysis or correction, as necessary.
MCIR Resource Materials:
Visit www.mcir.org for appropriate tip sheets and related resources
MICHIGANCAREIMPROVEMENTREGISTRY:DataQualityPrinciples&BestPracticeStrategiesJune3,2016/Page20of21
Make appropriate referrals, when necessary. Provider Best Practice (BP): The provider should document complete data for immunizations administered, in their practice, whether valid or invalid.
Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider Best Practice. • #06-01 MDHHS MCIR Policy for Site/User
Training and MCIR Training Checklist • MCIR DQI Business Plan
Perform required regional MCIR data analysis or correction, as necessary. Make appropriate referrals, when necessary.
MCIR Resource Materials:
Visit www.mcir.org for appropriate tip sheets and related resources
MICHIGANCAREIMPROVEMENTREGISTRY:DataQualityPrinciples&BestPracticeStrategiesJune3,2016/Page21of21
DATA QUALITY PRINCIPLE #11:
SUPREMACY OF MEDICAL RECORDS
Person medical records are of greater reliability in collecting immunization data than person billing records / CPT codes.
Example(s):
ü MCIR has not accepted billing data since 2003 ü MCIR accepts vaccine (clinical) data
Provider Best Practice (BP):
The provider should reference the individual’s clinical immunization record when adding data to the MCIR.
Regional MCIR Office BP Support: Reference the MCIR Regional Training Checklist in order to provide required user education on related MCIR legislation, policy and benefits, and/or and training on function and utilization. Reference MDHHS MCIR Policy Guide and the MCIR Data Quality Initiative (DQI) Business Plan for appropriate Regional MCIR procedures and IIS function, as it relates to the Provider Best Practice. • #06-01 MDHHS MCIR Policy for Site/User
Training and MCIR Training Checklist • MCIR DQI Business Plan
Perform required regional MCIR data analysis or correction, as necessary. Make appropriate referrals, when necessary.
MCIR Resource Materials:
Visit www.mcir.org for appropriate tip sheets and related resources