Appendix 2 HEDIS Roadmap: Section 7 2-1

Appendix 2—HEDIS Roadmap: Section 7 2-1 Section 7: Data Integration

Introduction

General information about how your organization integrates data into a HEDIS repository to calculate rates for the measurement year. This section also requests information about how your organization manages its HEDIS report production process, maintains its HEDIS software and ensures HEDIS data integrity.

Organization Organization name: information Date of completion:

Definitions

HEDIS A central system into which all claim or encounter, membership, practitioner, vendor repository and other data are loaded and where calculations are performed to produce measure rates and results.

Instructions  Where there are differences by product lines and products, provide a separate response for each product line and product subject to audit.  Complete applicable tables for each product line and product, adding columns when necessary.  Complete the appropriate tables in Section 7, depending on whether the HEDIS source code is: – Produced internally without a software vendor. – Produced using an NCQA-certified software vendor, whether the measure production is run in-house or outsourced to the certified software vendor. – Produced using a non-certified vendor, whether the measure production is run in- house or outsourced to the software vendor.  All questions relate to the measurement year systems and processes, unless otherwise indicated.

HEDIS 2009, Volume 5 2-2 Appendix 2—HEDIS Roadmap: Section 7 Data Integration and HEDIS Measure Production Responsibility

Table 7.1: Staff or type responsible for key steps in the HEDIS production process. Enter the number of persons responsible for each step; provide explanations where relevant. General HEDIS Number of Internal Production Functions Staff and Type Contracted Staff Vendor Name Data integration Data warehouse or repository Source code development Rate calculation or measure production Project management Other (indicate) Question Description Identify significant changes from the previous year’s HEDIS cycle.

Data Sources and Completeness

Table 7.2: Data files used, the date on which the files were loaded into the HEDIS repository and the date for planned data refresh for HEDIS reporting. Consider data received from vendors and any other external sources. Complete multiple tables if variations among product lines or products and add columns and rows, as appropriate. Planned Dates of Date Loaded Into Data Refreshes or Sources Data File Name HEDIS Repository Final Refresh Enrollment or membership Practitioner Claim or encounter Behavioral health Pharmacy Laboratory orders Lab results Vision care Public registry (e.g., immunization) Other Administrative database or supplemental data (describe)

Table 7.3: Consider all entities that provided or to which your organization delegated any aspect of data processing. Were any data excluded from HEDIS reporting for any reason? For example, incomplete data from a delegated claims vendor. Question Description What data were excluded? Why were the data excluded? What percentage of members, practitioners or claims or encounters was affected?

HEDIS 2009, Volume 5 Appendix 2—HEDIS Roadmap: Section 7 2-3 Table 7.4: Sampling and data refresh activities for reporting hybrid measures. Can Plan Reproduce Systematic Sample to Date of Select Sampling Original Additional Planned Method Sample Members for Date(s) of Measure Used Draw Oversample? Data Refresh Adult BMI Assessment Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents Childhood Immunization Status Lead Screening in Children Cervical Cancer Screening Colorectal Cancer Screening Care for Older Adults Cholesterol Management for Patients With Cardiovascular Conditions Controlling High Blood Pressure Comprehensive Diabetes Care Medication Reconciliation Post- Discharge Prenatal and Postpartum Care Frequency of Ongoing Prenatal Care Comprehensive Diabetes Care Medication Reconciliation Post- Discharge Prenatal and Postpartum Care Frequency of Ongoing Prenatal Care Well-Child Visits in the First 15 Months of Life Well Child Visits in the 3rd, 4th, 5th and 6th Years of Life Adolescent Well-Care Visits Weeks of Pregnancy at Time of Enrollment Question Description How were calculations handled with administrative data refresh?

HEDIS 2009, Volume 5 2-4 Appendix 2—HEDIS Roadmap: Section 7 Table 7.5: Amount of data used to report HEDIS data. Count services that represent a unique date of service, a unique provider identifier and a unique patient. Measurem Measurem Measurem Prior ent Year Prior Year ent Year Prior Year ent Year Type Of Service Year (PY) (MY) (PY) (MY) (PY) (MY) Product line Product Average per member per year (PMPY) ambulatory services Average PMPY inpatient services Average PMPY pharmacy Average PMPY behavioral health Average PMPY laboratory Question Description How were the PMPY numbers calculated? Indicate how each type of service was identified. Do you change your methodology from year to year? Explain.

Data Integration and Report Production (HEDIS Measures Produced Without Certified Software)

Table 7.6: Software packages, programming languages and mainframe or pc-based application programs your organization or vendor uses to prepare and calculate the measurement year HEDIS report. Consider all programs used to create denominators, numerators and samples. Software Package or Programming Language Activity or HEDIS Measures Function or Application Affected Data integration Data warehouse or HEDIS repository Source code development for HEDIS rate calculation

HEDIS 2009, Volume 5 Appendix 2—HEDIS Roadmap: Section 7 2-5 Table 7.7: Data integration and file consolidation in the HEDIS repository. Data Integration Question Description How are data integrated and consolidated for HEDIS reporting? Consider data from all sources and indicate if rates are calculated by querying the processing system online, creating extract files or through a separate database, data repository or warehouse. Describe the extract-transform-load (ETL) process for landing HEDIS data in the data warehouse or HEDIS data repository. How do you ensure that all data (including any supplemental or MRR data) are transferred and properly formatted? Describe any changes made to the data integration process for the measurement year Describe testing activities employed to validate any changes File Consolidation Question Description Describe the procedures used to link:  Claim or encounter (including vendor) data and membership data  Claim or encounter (including vendor) data and practitioner data With regard to accuracy of data integrated for HEDIS reporting:  What is your process for ensuring that the required level of coding detail is maintained?  How do you identify and handle duplicate records?  How do you identify and handle erroneous data?  How do you identify and handle missing data elements?  How do you ensure that the repository or warehouse accurately reflects the transaction files?  How do you ensure that no data are lost in the data integration process?  What algorithms do you use to check the reasonableness of data integrated to report HEDIS?  If your organization employs nonstandard HEDIS codes, how are they translated to standard codes for HEDIS reporting? Include a copy of the code mapping scheme and translation procedures.

HEDIS 2009, Volume 5 2-6 Appendix 2—HEDIS Roadmap: Section 7 Table 7.8: HEDIS measure production and source code development used to prepare and calculate the measurement year HEDIS report. Consider all programs used to create denominators, numerators and samples. Question Description Describe the background and relevant experience of the persons involved in developing source code for HEDIS production. How is their work overseen and monitored? Describe the process for producing source code for the measurement year, including development, oversight, review, testing and version control. Describe revisions made to previous source code to accommodate first-year reporting of measures or changes in technical specifications, data processing systems (e.g., claim or encounter, membership, practitioner, vendor) and HEDIS rate production. Describe the processes for running HEDIS production reports for the measurement year, including production control mechanisms, job logs, supervisory review, error detection and reruns. Describe the process for entering data into the Interactive Data Submission System or final HEDIS reporting format. Do you perform direct data entry or use an import template? Regarding how continuous enrollment and member months were calculated for the measurement year:  Describe how the continuous enrollment logic tracks member enrollment history, including separate coverage periods, change in ID number, change in relationship to subscriber, changes across product lines and reenrollment.  Describe how the member months logic determines member’s age, sex and the enrollment determination date (e.g., the first day, last day, 15th day of the month).  Describe any system or data limitation that precludes full implementation of HEDIS continuous enrollment or member months requirements as specified. Regarding calculation of hybrid measures for the measurement year:  Describe how hybrid samples are generated.  If applicable, describe how sample sizes are reduced using last year’s hybrid rate or this year’s administrative rates.  Describe how data obtained through medical record review are integrated back into the administrative data for HEDIS measure calculation.  Describe any system or data limitation that precludes full implementation of HEDIS sampling requirements as specified. Describe the tests and checks performed to validate the accuracy and completeness of:  Measure-specific rates.  Measure-specific denominators (i.e., eligible member population).  Member month calculations.

HEDIS 2009, Volume 5 Appendix 2—HEDIS Roadmap: Section 7 2-7 Data Integration and Report Production (HEDIS Measures Produced Using Certified Software)

Table 7.9: Software packages, programming languages and mainframe or pc-based application programs your organization or vendor uses to prepare and calculate the measurement year HEDIS report. Consider all programs used to create denominators, numerators and samples. Software Package or Programming Language or Activity or HEDIS Measures Function Application Affected Data integration Data warehouse or HEDIS repository Source code development for HEDIS rate calculation

Table 7.10: Information about data integration and consolidation into the HEDIS repository. Data Integration Question Description Are data from your organization transferred to the vendor’s systems? If so, provide an overview of the process. Describe how the data are mapped from the organization’s file formats to the vendor’s file formats. How do you ensure that all data (including MRR data) are transferred and properly formatted? Describe any changes made to the data integration process for the measurement year. Describe any testing activities employed to validate the changes. File Consolidation Question Description How does the vendor link:  Claim or encounter (including vendor) data and membership data.  Claim or encounter (including vendor) data and practitioner data. Regarding ensuring the accuracy of data integrated for HEDIS reporting:  What is your process for ensuring that the required level of coding detail is maintained?  How do you identify and handle duplicate records?  How do you identify and handle erroneous data?  How do you identify and handle missing data elements?  How do you ensure that the repository or warehouse accurately reflects the transaction files from the organization?  How do you and your vendor ensure that no data are lost in the data integration process?  What algorithms do you use to check the reasonableness of data integrated to report HEDIS?  If your organization employs nonstandard HEDIS codes, how do they translate to standard codes for HEDIS reporting? Include a copy of the code mapping scheme and translation procedures.

HEDIS 2009, Volume 5 2-8 Appendix 2—HEDIS Roadmap: Section 7 Table 7.11: HEDIS measure production used to prepare and calculate the measurement year HEDIS report. Consider all programs used to create denominators, numerators and samples. Questions Description If your organization is using certified software but produces the measures in-house, how do you ensure you are using the latest versions or patches of the vendor’s software? Describe the process for integrating the vendor- supplied information with the organization-supplied information (e.g., board certification, call answer timeliness, call abandonment) for the final HEDIS submission. Describe the process for entering data into the Interactive Data Submission System (IDSS) or final HEDIS reporting format. Do you perform direct data entry or use an import template? Regarding calculation of hybrid measures for the measurement year:  How are hybrid samples generated?  If applicable, describe how sample sizes are reduced using last year’s hybrid rate or this year’s administrative rates.  How are data obtained through medical record review integrated back into the administrative data for HEDIS measure calculation?  Describe any system or data limitation that precludes full implementation of HEDIS sampling requirements as specified. Describe the tests and checks performed to validate the accuracy and completeness of:  Measure-specific rates.  Measure-specific denominators (i.e., eligible member population).  Member month calculations.

HEDIS 2009, Volume 5 Appendix 2—HEDIS Roadmap: Section 7 2-9 System Security or Back-Ups

Table 7.12: Claim or encounter, membership and practitioner data processing systems. Question Description How are your data or systems backed up? How is data-access authorization assigned? What type of physical security, including fire protection and UPS, is in place? Have you experienced any unexpected or unplanned system downtime during the measurement year? If so, explain and describe how data integrity and completeness were validated. Have you restored data from back-up files during the measurement year? If so, explain. If so, explain and describe how data integrity and completeness were validated. Have you experienced data loss during the measurement year? If so, explain. If so, explain and describe how data integrity and completeness were validated. With regard to internal HEDIS repository, data warehouse or vendor HEDIS repository:  How are data or systems backed up?  How is data-access authorization assigned?  What type of physical security, including fire protection and UPS, is in place? Have you experienced any unexpected or unplanned system downtime during the measurement year? If so, explain and describe how data integrity and completeness were validated. Have you restored data from back-up files during the measurement year? If so, explain and describe how data integrity and completeness were validated. Have you experienced data loss during the measurement year? If so, explain. If so, explain and describe how data integrity and completeness were validated.

HEDIS 2009, Volume 5 2-10 Appendix 2—HEDIS Roadmap: Section 7 Requested Supporting Documentation

Provide the documents listed below and label them as instructed in the table. Use “NA” if the document is not applicable. Document Details Label Data integration flow Provide a flowchart that gives an overview of your management 7.1 chart information systems structure, including how all claim, encounter, membership, provider and vendor data are integrated for HEDIS reporting. HEDIS repository file Provide a complete file structure, file format and field definitions for 7.2 structure (if your HEDIS repository. applicable) Vendor mapping Provide a mapping document of the organization’s data elements to 7.3 documents (if using the NCQA-Certified Software’s file structure NCQA-certified software) Mapping of If your organization uses nonstandard codes for producing HEDIS, 7.4 nonstandard codes (if provide the mapping scheme used to translate codes to standard applicable) codes for HEDIS reporting Source code Provide a list of measures and the programmer assigned to its 7.5 development source code development. assignments (if non- certified source code is used) Disaster recovery or Provide documentation that describes your routine back-up 7.6 routine back-up processes and disaster recovery procedures. If documentation was processes previously submitted to the audit firm, submit it only if it has been revised since the last submission.

Section Contact

Who is responsible for completing this section of the Roadmap? Contact Name Title Company Address City, state, zip Telephone Fax E-mail address

HEDIS 2009, Volume 5 Appendix 2—HEDIS Roadmap: Section 7 2-11

HEDIS 2009, Volume 5