36C77620R0001-0001002.docx

PERFORMANCE WORK STATEMENT (PWS)

DEPARTMENT OF VETERANS AFFAIRS

Office of Reporting, Analytics, Performance, Improvement, Deployment (RAPID) Office of Performance Measurement (PM)

External Peer Review Program (EPRP) VI

February 19, 2020

Contents

1.0 BACKGROUND

The mission of the Department of Veterans Affairs (VA), Office of Performance Measurement (RAPID-PM) within the Office of Reporting, Analytics, Performance, Improvement, Deployment (RAPID) is to measure and monitor care, as well, as identify opportunities for improvement, ensuring the highest quality of care for Veterans. In meeting these goals, RAPID-PM strives to provide high quality, effective and efficient data and information services to those responsible for providing care to the Veterans at the point-of-care, as well as, throughout all the points of the Veterans’ health care in an effective, timely and compassionate manner.

RAPID-PM serves as a vehicle for effecting change in a balanced fashion. Key aspects of the Performance Measurement Program include the External Peer Review Program (EPRP) which through measurement development, review, analysis and monitoring the quality of care:

· Support transparency for VHA’s initiative to publicly report data

· Measure Improvements in Health Outcomes

· Identify opportunities for improvement, ensuring the highest quality of care for Veterans

· Provide customer-centric data, tools and reports that strengthen facility and system-level performance, quality of care, efficiency, resilience and enhance Veteran experience

The purpose of the External Peer Review Program Contract is to operate a system of external review of medical records and transition to electronic measurement to assess the quality of both inpatient and outpatient care across the continuum delivered by the Veterans Health Administration (VHA). The EPRP Program ensures that care provided to Veterans is evidence-based and delivered quickly and efficiently while maintaining a level of quality that meets or exceeds the standard of care. The work done through the EPRP contract is aligned with external comparators such as National Quality Forum (NQF), National Committee for Quality Assurance (NCQA), and The Joint Commission (TJC). EPRP is essential to the development, testing and validation of electronic measures and is considered the gold standard of measurement within the VHA.

The information generated by this work is also used in public reporting of VHA Medical Center performance. The Contract’s work directly impacts the quality of patient care as it is designed to measure and monitor, as well as identify opportunities for improvement, ensuring the highest quality of care for Veterans. The Program has and shall continue to successfully transition to support VHA programmatic changes and has increased transparency while remaining true to the basic concept and philosophy. Importantly, the Program provides an independent and impartial evaluation of the quality of care delivered to our Veterans.

Key services include working with VHA subject matter experts (SME) to independently and/or collaboratively build opportunities for the development, testing and validation of new measures and/or specifications. New measure development will support and drive ongoing quality improvement activities in VHA and enable performance comparison with external comparators. EPRP is and has proven to be essential regarding electronic measurement and Meaningful Use and is considered the gold standard for validation.

The Contract will provide for daily, monthly, quarterly and annual data and reports, in addition to the development of processes, tools and definitions to ensure data are comparable between facilities, Veterans Integrated Service Networks (VISNs) and external comparators. This data will be incorporated into VHA existing quality management reporting system. The Contractor is responsible for data integrity, ensuring all data are validated and tested for reliability. Additionally, stringent security standards are integrated into each stage of the process.

History VHA operated its own internal peer review organization (MEDIPRO - Medical District Initiated Peer Review Organization) from 1985 until March 1, 1991. As a decentralized program, the topic and criteria selected varied across the 27 Medical Districts. This made the system-wide assessment and comparison of data to support quality improvement across the system impossible.

VHA then established a system-wide, external peer review program modeled after the Department of Defense (DoD) EPRP. The first contract established by VHA emphasized individualized case review of acute inpatient diagnoses, surgical procedures and selected occurrences. Continuity of ambulatory care services and topics in long-term care and mental health were reviewed in subsequent years. In addition, development of practice guidelines for the purpose of assessing the comprehensive experience of the patient rather than specific diagnoses and procedures began. Data were abstracted on site at each VHA medical center. A physician peer review panel composed of board certified non-VHA clinicians reviewed cases identified by initial screening as having potential opportunities for improvement. While opportunities for system-wide improvement were identified, it was determined that of the nearly 132,000 cases reviewed, 95.2% met or exceeded community standards.

In 1998, the focus of the program changed from its earlier focus on individual case analysis to a system of data collection that would allow for population-based or pattern analysis through various levels of data aggregation. Evolution of the computerized medical record also streamlined the review process at the facility level. Data generated through the program became central to VHA’s system of network accountability for quality of care. VHA also used this contract to facilitate the development and implementation of clinical practice guidelines.

In 2003, the external peer review program’s focus expanded to include more emphasis on inpatient care, broadened Joint Commission/ORYX participation; validation of administrative data prior to implementation of fully automated quality measures; increased emphasis on special studies (e.g., Resident supervision, cancer care); and heightened data security protocols to meet or exceed VHA and federal policy. Full utilization of the computerized medical record at the medical center level allowed remote data abstraction to be more fully implemented with concomitant rigid data security policies.

The joint announcement in 2013 by VHA and DoD prioritizing the development of a single integrated electronic health record (iEHR) and the 2012 decision to meet the Office of the National Coordinator (ONC) for Health Information Technology’s certification requirements for Meaningful Use has accelerated the move toward electronic measurement (e-Measures). Consequently, there is a need to develop, test, validate and deploy electronic quality measures within the VistA (Veterans Health Information Systems and Technology Architecture) environment to maintain measure alignment and consistency with the national quality strategy. As VHA and DoD move toward a single integrated e HR there will be additional need to work in both VistA and the new Cerner environments during the transition. This will require additional hardware and software for the Cerner environment.

EPRP is and has proven to be essential regarding electronic measurement and Meaningful Use and is considered the gold standard for validation.

2.0 APPLICABLE DOCUMENTS

In the performance of the tasks associated with this Performance Work Statement, the Contractor will comply with the following:

1. 44 U.S.C. § 3541-3549, “Federal Information Security Management Act (FISMA) of 2002”

2. “Federal Information Security Modernization Act of 2014”

3. Federal Information Processing Standards (FIPS) Publication 140-2, “Security Requirements for Cryptographic Modules”

4. FIPS Pub 199. Standards for Security Categorization of Federal Information and Information Systems, February 2004

5. FIPS Pub 200, Minimum Security Requirements for Federal Information and Information Systems, March 2016

6. FIPS Pub 201-2, “Personal Identity Verification of Federal Employees and Contractors,” August 2013

7. 10 U.S.C. § 2224, "Defense Information Assurance Program"

8. Carnegie Mellon Software Engineering Institute, Capability Maturity Model® Integration for Development (CMMI-DEV), Version 1.3 November 2010; and Carnegie Mellon Software Engineering Institute, Capability Maturity Model® Integration for Acquisition (CMMI-ACQ), Version 1.3 November 2010

9. 5 U.S.C. § 552a, as amended, “The Privacy Act of 1974”

10. Public Law 109-461, Veterans Benefits, Health Care, and Information Technology Act of 2006, Title IX, Information Security Matters

11. 42 U.S.C. § 2000d “Title VI of the Civil Rights Act of 1964”

12. VA Directive 0710, “Personnel Security and Suitability Program,” June 4, 2010, http://www.va.gov/vapubs/

13. VA Handbook 0710, Personnel Security and Suitability Security Program, May 2, 2016, http://www.va.gov/vapubs

14. VA Directive and Handbook 6102, “Internet/Intranet Services,” July 15, 2008

15. 36 C.F.R. Part 1194 “Electronic and Information Technology Accessibility Standards,” July 1, 2003

16. Office of Management and Budget (OMB) Circular A-130, “Managing Federal Information as a Strategic Resource,” July 28, 2016

17. 32 C.F.R. Part 199, “Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)”

18. An Introductory Resource Guide for Implementing the Health Insurance Portability and Accountability Act (HIPAA) Security Rule, October 2008

19. Sections 504 and 508 of the Rehabilitation Act (29 U.S.C. § 794d), as amended, January 18, 2017

20. Homeland Security Presidential Directive (12) (HSPD-12), August 27, 2004

21. VA Directive 6500, “Managing Information Security Risk: VA Information Security Program,” September 20, 2012

22. VA Handbook 6500, “Risk Management Framework for VA Information Systems – Tier 3: VA Information Security Program,” March 10, 2015

23. VA Handbook 6500.1, “Electronic Media Sanitization,” November 03, 2008

24. VA Handbook 6500.2, “Management of Breaches Involving Sensitive Personal Information (SPI)”, July 28, 2016

25. VA Handbook 6500.3, “Assessment, Authorization, And Continuous Monitoring of VA Information Systems,” February 3, 2014

26. VA Handbook 6500.5, “Incorporating Security and Privacy in System Development Lifecycle”, March 22, 2010

27. VA Handbook 6500.6, “Contract Security,” March 12, 2010

28. VA Handbook 6500.8, “Information System Contingency Planning”, April 6, 2011

29. OI&T Process Asset Library (PAL), https://www.va.gov/process/ . Reference Process Maps at https://www.va.gov/process/maps.asp and Artifact templates at https://www.va.gov/process/artifacts.asp

30. One-VA Technical Reference Model (TRM) (reference at https://www.va.gov/trm/TRMHomePage.aspx)

31. VA Directive 6508, “Implementation of Privacy Threshold Analysis and Privacy Impact Assessment,” October 15, 2014

32. VA Handbook 6508.1, “Procedures for Privacy Threshold Analysis and Privacy Impact Assessment,” July 30, 2015

33. VA Handbook 6510, “VA Identity and Access Management”, January 15, 2016

34. VA Directive 6300, Records and Information Management, February 26, 2009

35. VA Handbook, 6300.1, Records Management Procedures, March 24, 2010

36. NIST SP 800-37 Rev 1, Guide for Applying the Risk Management Framework to Federal Information Systems: A Security Life Cycle Approach, June 5, 2014

37. NIST SP 800-53 Rev. 4, Security and Privacy Controls for Federal Information Systems and Organizations, January 22, 2015

38. OMB Memorandum, “Transition to IPv6”, September 28, 2010

39. VA Directive 0735, Homeland Security Presidential Directive 12 (HSPD-12) Program, October 26, 2015

40. VA Handbook 0735, Homeland Security Presidential Directive 12 (HSPD-12) Program, March 24, 2014

41. OMB Memorandum M-06-18, Acquisition of Products and Services for Implementation of HSPD-12, June 30, 2006

42. OMB Memorandum 04-04, E-Authentication Guidance for Federal Agencies, December 16, 2003

43. OMB Memorandum 05-24, Implementation of Homeland Security Presidential Directive (HSPD) 12 – Policy for a Common Identification Standard for Federal Employees and Contractors, August 5, 2005

44. OMB memorandum M-11-11, “Continued Implementation of Homeland Security Presidential Directive (HSPD) 12 – Policy for a Common Identification Standard for Federal Employees and Contractors, February 3, 2011

45. OMB Memorandum, Guidance for Homeland Security Presidential Directive (HSPD) 12 Implementation, May 23, 2008

46. Federal Identity, Credential, and Access Management (FICAM) Roadmap and Implementation Guidance, December 2, 2011

47. NIST SP 800-116 Rev 1, Guidelines for the Use of Personal Identity Verification (PIV) Credentials in Facility Access, June 2018

48. OMB Memorandum M-07-16, Safeguarding Against and Responding to the Breach of Personally Identifiable Information, May 22, 2007

49. NIST SP 800-63-3, 800-63A, 800-63B, 800-63C, Digital Identity Guidelines, June 2017

50. NIST SP 800-157, Guidelines for Derived PIV Credentials, December 2014

51. NIST SP 800-164, Guidelines on Hardware-Rooted Security in Mobile Devices (Draft), October 2012

52. Draft National Institute of Standards and Technology Interagency Report (NISTIR) 7981 Mobile, PIV, and Authentication, March 2014

53. VA Memorandum, VAIQ #7100147, Continued Implementation of Homeland Security Presidential Directive 12 (HSPD-12), April 29, 2011 (reference https://www.voa.va.gov/documentlistpublic.aspx?NodeID=514)

54. IAM Identity Management Business Requirements Guidance document, May 2013, (reference Enterprise Architecture Section, PIV/IAM (reference https://www.voa.va.gov/documentlistpublic.aspx?NodeID=514)

55. VA Memorandum “Mandate to meet PIV Requirements for New and Existing Systems” (VAIQ# 7712300), June 30, 2015, https://www.voa.va.gov/DocumentView.aspx?DocumentID=4846

56. Trusted Internet Connections (TIC) Reference Architecture Document, Version 2.2, Federal Interagency Technical Reference Architectures, Department of Homeland Security, June 19, 2017, https://www.dhs.gov/sites/default/files/publications/TIC_Ref_Arch_v2.2_2017.pdf

57. OMB Memorandum M-08-05, “Implementation of Trusted Internet Connections (TIC), November 20, 2007

58. OMB Memorandum M-08-23, Securing the Federal Government’s Domain Name System Infrastructure, August 22, 2008

59. VA Memorandum, VAIQ #7497987, Compliance – Electronic Product Environmental Assessment Tool (EPEAT) – IT Electronic Equipment, August 11, 2014 (reference Document Libraries, EPEAT/Green Purchasing Section, https://www.voa.va.gov/documentlistpublic.aspx?NodeID=552)

60. Sections 524 and 525 of the Energy Independence and Security Act of 2007, (Public Law 110–140), December 19, 2007

61. Section 104 of the Energy Policy Act of 2005, (Public Law 109–58), August 8, 2005

62. Executive Order 13834, “Efficient Federal Operations”, dated May 17, 2018

63. Executive Order 13221, “Energy-Efficient Standby Power Devices,” August 2, 2001

64. VA Directive 0058, “VA Green Purchasing Program”, July 19, 2013

65. VA Handbook 0058, “VA Green Purchasing Program”, July 19, 2013

66. Office of Information Security (OIS) VAIQ #7424808 Memorandum, “Remote Access”, January 15, 2014, https://www.voa.va.gov/DocumentListPublic.aspx?NodeId=28

67. Clinger-Cohen Act of 1996, 40 U.S.C. §11101 and §11103

68. VA Memorandum, “Implementation of Federal Personal Identity Verification (PIV) Credentials for Federal and Contractor Access to VA IT Systems”, (VAIQ# 7614373) July 9, 2015, https://www.voa.va.gov/DocumentListPublic.aspx?NodeId=28

69. VA Memorandum “Mandatory Use of PIV Multifactor Authentication to VA Information System” (VAIQ# 7613595), June 30, 2015, https://www.voa.va.gov/DocumentListPublic.aspx?NodeId=28

70. VA Memorandum “Mandatory Use of PIV Multifactor Authentication for Users with Elevated Privileges” (VAIQ# 7613597), June 30, 2015; https://www.voa.va.gov/DocumentListPublic.aspx?NodeId=28

71. “Veteran Focused Integration Process (VIP) Guide 3.2”, December 2018, https://www.voa.va.gov/DocumentView.aspx?DocumentID=4371

72. “VIP Release Process Guide”, Version 1.4, May 2016, https://www.voa.va.gov/DocumentView.aspx?DocumentID=4411

73. “POLARIS User Guide”, Version 1.9, March 2017, https://www.voa.va.gov/DocumentView.aspx?DocumentID=4412

74. VA Memorandum “Use of Personal Email (VAIQ #7581492)”, April 24, 2015, https://www.voa.va.gov/DocumentListPublic.aspx?NodeId=28

3.0 SCOPE OF WORK

3.1 The Contractor will operate a system of external review of medical records to assess the quality of both inpatient and outpatient care across the continuum throughout the VHA Healthcare System. Record review will consist primarily of review of the standardized electronic record used in the VHA. This includes reviewing remote data via the reports tab of the electronic health record (EHR) and any paper-based medical information to examine the continuum of care across VHA. This method will be continuously refined as the electronic medical record system transitions to an integrated EHR (Cerner) with DoD. The Contractor will work collaboratively with RAPID-PM through the Contracting Officer or COR to ensure that the components and processes used to measure the quality of care delivered meet the intent of the sponsoring VHA Program Offices.

Key services include working with VHA subject matter experts (SME) to independently and/or collaboratively to build opportunities for the development, testing and validation of new measures and/or specifications. New measure development will support and drive ongoing quality improvement activities in VHA and enable performance comparison with external comparators.

The Contractor will test and prepare measure instruments to transform VHA data collection from abstraction to extraction. This work will occur within the existing EHR and center on using EPRP to develop and validate electronic quality measures that will extract data from the VHA corporate data warehouse (CDW). The Contractor performing EPRP will continue with abstracting records for measures with unstandardized data fields that are best assessed using qualitative text-based information and for ongoing quality assurance of electronic measures.

Contractor performance will commence within thirty (30) calendar days of Contract award. Initial abstraction shall be completed within thirty (30) calendar days of receipt of first pull list once the Contract is awarded.

4.0 PERFORMANCE DETAILS

4.1 PERFORMANCE PERIOD

The performance period will be six (6) months base period from date of award. The VHA will retain the option to extend the Contract an additional four (4) years, for periods of one (1) year at a time, subject to the availability of funds.

Any work at the Government site will not take place on Federal holidays or weekends unless directed by the Contracting Officer (CO).

The ten (10) Federal holidays set by law (USC Title 5 Section 6103) that VHA follows:

Under current definitions, four are set by date:

If any of the above falls on a Saturday, then Friday will be observed as a holiday. Similarly, if one falls on a Sunday, then Monday will be observed as a holiday.

The other six (6) are set by a day of the week and month:

4.2 PLACE OF PERFORMANCE

Tasks under this PWS will be performed in VHA facilities located throughout the VHA system. The Contractor will provide onsite Exits no more than monthly after negotiating visitation date with the assigned VHA (EPRP) liaison. Minimally, the Contractor will provide an onsite Exit Conference once during Quarter one and once during Quarter three. Work may be performed remotely with prior approval of the Contracting Officer’s Representative (COR)/Program Manager (PM).

4.3 TRAVEL

The Government anticipates travel under this effort to perform the associated tasks, primarily monthly Exit conferences. The Government will only pay the travel for one Abstractor per site visit per month. This will extend to Regional Manager site visits at the discretion of the VHA COR/PM.

Additionally, travel is anticipated to attend program-related meetings or conferences through the period of performance. The total estimated number of trips in support of program administration related meetings is 2 annually. The anticipated meeting location will be those determined to be cost -effective for the government. Meetings have an estimated duration of 3-5 days.

When the Contractor may be required to travel in performance this Contract, allowable travel and per diem charges governed by FAR Part 31, and the Federal Travel Regulations are handled as a direct reimbursable by the agency and will be priced on a fixed price, not to exceed (NTE) line item. Travel in performance of the Contract shall only be compensated to the extent authorized by the ordering agency and required advanced concurrent by the COR. Contractor travel within the local commuting area will not be reimbursed.

The Contractor’s invoice shall include copies of all receipts that support the travel costs claimed in the invoice. The Contractor will use only the minimum number of travelers and rental cars needed to accomplish the task(s), to be determined based on tasks. Any travel shall be directly related to the requirements set forth is this PWS. The Government also expects the Contractor to minimize travel costs where possible.

(VHA medical center, see ATTACHMENT I – FY20 Facilities List)

5.0 SPECIFIC TASKS AND DELIVERABLES

The Contractor shall perform the following Tasks:

5.1 Task 1- Preparation for Data Collection

The Contractor shall collect data from both the predominantly electronic medical records and any paper medical records to measure the identified indicators of healthcare quality that cannot be collected electronically on a national level. Only data that is part of the official medical record shall be used. In preparation for data collection the Contractor shall develop measure specifications.

In collaboration with RAPID-PM, the Contractor shall develop measure specifications based on National Quality Forum (NQF), VHA and/or external accrediting bodies measures proposed by RAPID-PM to include definitions, data set questions and automated scoring algorithms and specifications for software to be used in the abstraction process for medical record reviews as communicated by the COR/PM. The Contractor shall work with RAPID-PM to ensure that the data being collected meets the intent of the information requirements of the Program Offices and the Measurement Program- (for example, specific measure specifications consistent with the measures that the Mental Health Program defines (i.e., request to screen all Veterans for depression and suicide).

The Contractor shall provide RAPID-PM with electronic copies of the completed measure specifications including dataset questions with operational definitions and scoring algorithms. The format of the dataset questions, operational definitions and scoring algorithms shall be similar to those used by external comparators such as the Joint Commission for ORYX measures; with any revisions to that format mutually agreed upon by RAPID-PM and the Contractor.

The Contractor shall develop, maintain and provide computerized scoring algorithms incorporating the data elements for each of the review areas/review topics. Electronic versions of the scoring algorithms will be provided to RAPID-PM in both mnemonic and phrased form. Computerized scoring algorithms shall incorporate the measure specifications so that data can be abstracted from the electronic records using a computer which downloads data into transmittable files. Scoring algorithms will be used to produce rates for the measures and targets for the measures may be changed as the VHA goals change. Algorithms shall be provided electronically in a form acceptable with RAPID-PM standardized coding practices. All data first produced (as defined by Federal Acquisition Regulation 52.227-14) under this Contract by Contractor shall be delivered to VA and owned by VA, to include the algorithms.

The Contractor shall develop, maintain and provide a common set of core data elements to be collected for all reviews incorporating demographic, diagnostic, procedural and follow-up aspects of care and others as determined by RAPID-PM.

The Contractor shall provide dataset questions within 30 days of the quarter to identify all the data to be gathered in the review process. All Abstractors under this Contract shall be proficient in all changes in data collection, content areas of study, software, etc. prior to implementation. All education related to VHA data collection or evaluation provided to the Abstractors shall be provided by the Contractor simultaneously to the RAPID-PM and may be disseminated to VHA if determined necessary by RAPID-PM.

Specifications for a new tool or significant change to existing tools are categorized as Low to Moderate or High Complexity as follows:

· Low to Moderate Complexity Specifications – 0-100 questions

· High Complexity Specifications- 101-150 questions

The Contractor shall develop measure specifications for all EPRP related VHA Performance Measures including those applicable to external accrediting bodies (i.e., the Joint Commission (TJC) or Commission on Accreditation of Rehabilitation Facilities (CARF)) and/or community standards organizations (i.e., National Committee for Quality Assurance (NCQA) or National Quality Standard (NQS) measures)), as well as, specialized and e-measurement studies. These measure specifications shall be included in electronic Technical Manual on the RAPID-PM website and shall be updated with all changes made to the measure and certified to match dataset questions/algorithms prior to the final copy being sent quarterly to RAPID-PM. Additionally, specialized focused studies that are initial analysis into emerging areas/topics, which may be designed to respond to an official inquiry, confirm a finding, are pilot in nature and/or e-measurement studies are not contained in the electronic Technical Manual unless they move to measurement status.

The abstraction (data collection process) performed for this Contract are at present retrospective and consist primarily of electronic record review. The monthly sampling for review shall include specialized focused studies and testing and data validation of e-measures. The plan for the first-year cycle shall include abstracting up to 600,000 records to determine the quality of prevention services, acute care and chronic disease management.

The Contractor shall:

1. Conduct monthly record abstractions: RAPID-PM will provide the Contractor with an electronic list of patient specific cases (the pull list) for abstraction at least monthly for the primary review of records and more often if necessary, for additional reviews. The pull lists average is 50,000 records across VHA. The Contractor shall download the pull list into an electronic database and provide the same list to each VHA facility as identified. The timing of communication of the pull lists to the facilities/EPRP liaisons shall be determined collaboratively between the Contractor and the PM. RAPID-PM will transmit the pull lists to the Contractor approximately 1-2 times per month; however, this may change if for example a specialized focused study is added or; if there are corrections to the list which was transmitted that month are necessary.

The Contractor shall:

· Validate that records on the pull list for review as appropriate for inclusion in the sample using a specific set of criteria developed; for example, if a record is pulled for a patient with a presumed diagnosis of diabetes, the Abstractor may be asked to look for a physician’s diagnosis, use of insulin, etc. to validate the diagnosis code;

· Abstract data from the medical records using only VHA approved access methods, on site and inside of VHA firewall or remotely using Cisco Connect Anywhere or other approved VHA (VHA version of the Virtual Private Network) connections. The Contractor shall only accept information that is documented in the permanent medical record (paper or electronic) in text or checklist format. Some documentation may be found only in a paper format (e.g., notes from providers outside of the VHA system). Documentation filed in the paper record shall clearly be part of the permanent medical record and shall conform to all internal and external medico-legal requirements for documentation (i.e. full patient identification including name and SSN identifier, date, author identified, authenticated/signed, etc.). Documentation that does not meet this standard may not be included. Electronic health record health summaries that aggregate relevant health data generated as part of care delivery may be included in the data collected;

· Use devices, including portable, for this Contract that are secured with VHA approved encryption and are not to be used for any other purposes. Devices may need to be upgraded as EHR evolves, requiring dual access and potentially additional hardware and software as the integrated EHR transitions. Any equipment utilized for this Contract shall be made available for random audits of compliance with VHA security requirement;

· Provide the facility with a list of data for each record reviewed that was not accessible, could not be found in the electronic medical record or potentially “failing” cases (for example, a Data Accountability Checklist (DAC)) which would include identified measures and elements which were “not met” or found during the abstraction process). All available data is abstracted via remote access to the electronic medical records and missing data is provided by the facility during the review. All changes shall be made and incorporated prior to the final Exit Conference.

2. Conduct an EXIT conference: Contractor Abstractors shall visit the assigned VHA medical centers minimally twice a year but no more than monthly after negotiating visitation date with the assigned VHA (EPRP) liaison. The Government shall only pay the travel for one Abstractor per site visit per month. The travel expenses for any additional Abstractors shall be borne by the Contractor. Monthly Abstractor review with the facility includes (see below). If an Abstractor(s) is/are onsite he/she shall do the following:

· Onsite review with facility EPRP liaison of data elements not found through remote review. The facility EPRP liaison may provide relevant medical documentation missed in the offsite abstraction. These data will be entered into the abstraction tool by the Abstractor during the onsite visit;

Abstractors shall provide/present the facility-level findings (to include interpretations and analysis) to facility stakeholders; provide the facility with a written summary EXIT Guide (EXIT) in an electronic version which will include aggregate data from the facility’s monthly review. The EPRP Exit Conference shall be designed to meet the facility’s needs. The EPRP Liaison determines the format of the Exit Conference but the EPRP Abstractor shall have some suggestions about what might be helpful and of interest. EPRP Abstractors shall be trained to do more than just read the numbers on the report. For example, at the first Exit Conference of each quarter, the Abstractor shall provide an overview of the changes effective for the current quarter, such as:

· Changes to existing questions and rules

· New measures

· Deleted measures

· Changes to measure Scoring Algorithm

· The Abstractors shall also discuss things like

· Precisely what information the questions are seeking

· Why the documentation doesn’t meet the intent of the questions they shall answer

· How documentation could be improved to meet the intent of the questions

· What is included in the numerator and denominator of the measures

· Once the Exit Conference has started, the Abstractor shall not make any changes to the data. If the VA Liaison feels a change is needed, he/she will need to follow the process for requesting reconsideration.

· The dates of the Exit Conference will be confirmed and established with each facility and provided to the PM two weeks before the Exit Conference, unless otherwise agreed upon by the facility and Contractor and approved by the PM. A monthly summary of dates and times of each facility Exit Conference including timelines to original data notified to PM and facility and days from the pull list will be detailed in the monthly report;

· Exit Conference monitoring shall be done remotely by Contractor Regional Managers (RM). If there are any unresolved issues the RM will elevate the issue to the Contractor’s Director of Field Operations who will discuss with VHA COR/PM as needed. The RM shall attend Exit Conferences at the discretion of the VHA COR/PM to better orient or provide more in-depth review or assist on resolving issues. These site visits will be covered under the Contract travel line item.

· Abstractors and EPRP liaisons may be required to sign a negotiated agreement to the terms of the visitation as decided upon by EPRP PM;

· Abstraction shall take place during normal business hours when visiting the facility unless otherwise agreed upon by the liaison. Abstractors shall not be on VHA premises without the liaison or assigned back-up person present;

· Abstractors shall download the finalized data abstracted via a secure method to the Contractor’s central processing area ensuring that all data security standards are met;

· Tele, Web or Videoconferencing Exit Conferences shall occur in lieu of onsite visit with PM approval;

· Post Exit Conference Reconsideration process occurs when facility personnel and the Abstractor do not agree on whether data is appropriate for inclusion and/or the facility finds additional documentation after the Exit Conference. Note: The Abstractor shall not change the data once the Exit Conference has started.

· Only Accountability measures are eligible for reconsideration.

· There are no reconsiderations of Quality Indicators or Pilot Measures.

· The reconsideration process starts with an initial review. The initial review is completed by VHA COR/PM. If it is readily apparent that reconsideration does not change the outcome or if the request is past two working days of the Exit Conference, the case is not accepted for reconsideration. Notification to this effect is made via email by the PM. If accepted for reconsideration, the facility is notified by e-mail by the PM and shall then provide hardcopy of the following (via overnight and tracked delivery) to the Contractor:

· Name of facility requesting reconsideration

· Contact name and number

· E-mail address to send updated reports, if necessary

· Pull List date under which the case was reviewed

· Exit date

· Short synopsis of the issue where reconsideration is being asked

· Copy of the Data Accountability Checklist (DAC) with the indicator and mnemonic in question

· Supporting documentation that will serve to provide Quality Insights with a full picture of the patient situations (including applicable ED notes, MD progress notes, admission H&P, discharge summary or anything else identified as required to be submitted)

· The Contractor shall review all accepted reconsideration cases and determine if the data provided meets the specification for compliance as outlined in the VHA Technical Manual. The Contractor shall discuss any request that cannot be clearly determined with the PM and a final determination is made.

· When a final determination has been made, the Contractor shall provide (via e-mail) the requesting facility and PM with the final outcome of the reconsideration. If the outcome results in a change in the Exit Report, the e-mail shall also outline that change and timeframe when an updated Exit Report shall be provided to the facility.

· If facilities are unable to resolve the case at the local level with assistance from the Regional Manager, the issue shall be forwarded to VHA COR/PM for a final decision.

3. Establishment and maintenance of a database: The Contractor shall develop and maintain a database of specifications, specifically individual data elements. Additionally, a database containing all data that can be linked to VHA’s web-site shall be included. The Contractor shall develop and maintain a database for the comparison of individual medical centers to its VISN groupings, the entire VHA system and other groupings as requested.

4. Data Transmission: The Contractor shall secure daily, monthly and quarterly transmission of data at the facility, VISN and National levels.

5. Report Preparation /Distribution: The Contractor shall prepare and distribute Summary Reports of total cases identified and reviewed, including, which cases were pulled based on codes, which cases failed validation and why. This shall be presented to COR/PM monthly.

6. Personnel: The Contractor shall recruit, orient and train Contractor staff including training on the development of the measure abstraction tools, the data collection system, the quality control system, the administrative processes, the reporting system, data confidentiality requirements, ongoing updates and competency reviews and the philosophy of continuous quality improvement with annual program summary report.

7. Quality Assurance Programs: The Contractor shall develop, implement and maintain an internal (abstraction related) quality assurance program to ensure a strong data reliability process that includes assessment of accuracy of Abstractors and inter-rater reliability of the abstraction tools, as approved by the RAPID-PM.

8. Surveillance: The Contractor shall provide constant surveillance to assure that appropriate acceptable security requirements related to handling confidential data are maintained. Ensure secure methods of data transmission from point of abstraction to Contractor and back to RAPID-PM which shall be approved by VHA.

9. Data Security: The Contractor shall ensure confidentiality of both sensitive patient medical, patient identifiable and quality assurance data in accordance with Federal Regulations governing same as outlined in the applicable documents listed Section 2 of this document.

10. Data Storage: The Contractor shall maintain data through the life of the Contract; once the Contract has expired, the Contractor shall coordinate the transfer of that data to RAPID-PM. VA shall own that data.

11. E-measurement: The Contractor in collaboration with RAPID-PM shall utilize both VHA and/or Contractor staff to modify existing abstraction-based measure specifications to e-Measure specifications. This includes development of data abstraction tools and algorithms that can be used for validation of e-Measures. For example, plans are underway to reduce the number of HEDIS and ORYX measures abstracted and convert them to e-Measurement. EPRP will be used for development and validation. Anticipated areas of focus include expansion of Mental Health Care review (inpatient and outpatient), Prevention, Stroke Care and Ethics Policy monitoring. The Contractor shall map current measure data elements, test and validate current identified measures for transition to extraction, and ensure the e-Measure specifications are consistent with external specifications.

12. Specialized Focused Studies: The Contractor shall develop, test, validate and implement focused studies that are initial analysis into emerging areas/topics, which may be designed to respond to an official inquiry, confirm a finding or are pilot in nature.

Deliverable 1.1 New Technical Specifications Low to Moderate Complexity For this deliverable Low to Moderate complexity is defined as 0-100 questions. Quantity up to 3. New Technical Specifications shall be due no later than ten (10) business days after the quarter.

OPTIONAL Deliverable 1.1a New Technical Specifications Low to Moderate Complexity Additional Quantity (up to 7) will be completed as outlined in Task 1, Deliverable 1.1. New Technical Specifications shall be due no later than ten (10) business days after the quarter.

Deliverable 1.2 New Technical Specifications High Complexity For this deliverable High complexity is defined as 101-150 questions.

New Technical Specifications shall be due no later than fifteen (15) business days after the quarter.

5.2 Task 2- Technical Specification Revision (Quarterly)

The Contractor shall provide revisions/modifications to the technical specifications including data set questions and algorithms as determined by RAPID-PM and in consideration of the Contractor’s experience with implementation.

· All dataset questions shall be available in a database and the Contractor shall provide RAPID-PM with electronic versions as updated and on a quarterly basis.

· The Contractor shall provide a report of dataset questions not utilized in the scoring algorithms quarterly at the time of dataset questions review for the following quarter.

· The Contractor shall incorporate updates to measure related documentation required by external accrediting bodies (i.e., TJC or CARF) and/or community standards (i.e., NCQA or NQS) measures as they become available and shall provide abstracted data in a format required for transmission of said data to that accrediting body. Major updates or revisions occur every six months (TJC) and annually for NCQA; however, quarterly updates will occur as needed between the major revisions. Transmission of data to the accrediting body occurs quarterly.

· The Contractor shall incorporate updates to the applicable measures required by external accrediting bodies (i.e. TJC or CARF) and/or community standards (i.e. NCQA or NQS) as they become available and shall structure a data abstraction tool and scoring algorithm to allow collection and reporting of these measures for the VHA.

· The Contractor shall develop, maintain and provide a common set of core data elements to be collected for all reviews incorporating demographic, diagnostic, procedural and follow-up aspects of care and others as determined by RAPID-PM.

· The Contractor shall provide dataset questions quarterly (in advance of their implementation) to identify all the data to be gathered in the review process. Contractor shall be proficient in all changes in data collection, content areas of study, software, etc. prior to implementation. All education related to VHA data collection or evaluation provided to the Abstractors shall be provided simultaneously to the COR/PM and may be disseminated to VHA if determined necessary by RAPID-PM.

Deliverable 2.1: Technical Specification Revision (Quarterly):

Revise/refine existing technical specifications as needed; the quarterly average of changes may be estimated at 75 specification changes (for example, including a population for a screening measure that the Program Office requests to include). This process (additions, deletions and revisions) to technical specifications, most commonly the data abstraction tools and computerized scoring algorithms and reports, shall occur quarterly. Changes are made to technical specifications on a quarterly basis and finalized specifications are due ten (10) business days after the end of the quarter, unless otherwise needed, as with a Specialized study.

5.3 Task 3- Abstraction (monthly)

The system for Abstraction (record review) of the patient specific medical records shall be designed to ensure all data has been retrieved. The Contractor shall receive a list of records to be reviewed each month. Records (identified by control number) not reviewed because the case did not meet the topic validation guidelines will be identified and aggregated monthly and sent to RAPID-PM. The Contractor shall utilize the following to perform these assessments:

· A Data Accountability Checklist (DAC) shall be completed for each record abstracted, unless otherwise directed by PM. DACs alert facilities of data that could not be located during the monthly record review so that facilities will have an opportunity to locate missing data or correct inaccurate data and have the Abstractor enter it into the database before completion of the Exit Conference. The Contractor shall provide the set of DACs to the liaison for that review 2 calendar days but no more than 4 calendar days prior to the Exit Conference date.

· If information from the DAC or review is located after the Exit conference, documentation to support the element(s) or measure(s) found on the DAC shall be reconsidered by the Contractor clinician staff, with the explicit approval of the PM. With the approval of the PM, the EPRP liaison requesting the reconsideration shall forward request and supporting documentation within 2 working days of the Exit Conference to the Contractor for further clinician evaluation. The reconsideration process occurs monthly with approximately 100 cases re-reviewed per quarter. Information located after the publication of the pull list will not be included in abstraction. The Contractor in collaboration with the PM shall work to determine a final decision regarding the reconsideration request. The Contractor shall provide the decision and any supporting information as applicable to the requesting facility in an email within 7-10 business days following receipt of request to reconsider. Data shall be updated according to the change. A quarterly tracking method shall monitor all reconsiderations and suggest modifications to dataset questions or scoring based on the reconsiderations from the quarter.

· The Contractor shall utilize the most current version of the measure specifications and data abstraction tools for immediate implementation of medical record reviews within 30 calendar days prior to the expiration of the current Contract to maintain continuity of the Performance Measurement Program through the Fiscal Year under review.

· Measure specifications specifically data abstraction tools/algorithms shall be developed by the Contractor in collaboration with RAPID-PM. The measures themselves will be proposed by RAPID-PM based upon the recommendation from Program Offices in the VHA. The Contractor shall keep RAPID-PM appraised of measurement changes supported by national measure developers (such as The Joint Commission; the National Committee for Quality Assurance; HEDIS) on a quarterly basis.

· The Contractor shall revise existing measure specifications and data abstraction tools/algorithms as requested by RAPID-PM. Revision/modification of existing tools are generally minor; but new measures are the most likely to be revised/modified. New measures may be developed throughout the year. This may require the development of additional data elements, mapping, dataset questions and algorithms. An example of a new measure would be screening for colorectal cancer with additional data elements to determine referral and follow-up. Generally, older measures are not changed except for yearly updates. An example of a change in an older measure would be the change in the time during which an influenza immunization might be given if the CDC changes their guidelines and/or an influenza vaccine shortage exists. Any change to a measure usually results in a change in the scoring algorithm. The Contractor shall expect to make approximately 75 specification changes per quarter.

· Reviews shall be completed as outlined in plan (5.1). The Contractor/Abstractor shall negotiate the date of the EXIT conference with the Facility EPRP Liaison to ensure that adequate medical center staff are available to assist with various aspects of data abstraction needed to ensure a thorough review. Exceptions to the on-site visit shall be given by the PM and the Contractor (collaboratively) if agreed to by the Abstractor, the facility EPRP liaison/Quality Manager and the VISN Quality Management Officer. Formal communication among those individuals to discuss the reason for the exception, the length of time that the exception is being requested and the consents of all involved will be completed before the exception can be finalized.

Deliverable 3.1 Record Review Record reviews (up to 425,000) will be completed as outlined in plan (5.1.1). Contractor shall start record abstraction within thirty (30) calendar days of Contract award. First abstraction shall be completed within thirty (30) calendar days of receipt of first pull list once the Contract is awarded. Each monthly case list shall be completed within thirty (30) calendar days of issue.

OPTIONAL Deliverable 3.1a Record Review Additional Quantity of up to 175,000 records will be completed as outlined in Task 3, Deliverable 3.1.