P09 - PWS EPRP 8.8.24_DRAFT.pdf

PERFORMANCE WORK STATEMENT (PWS)

DEPARTMENT OF VETERANS AFFAIRS

Office of Analytics and Performance Improvement (API) Performance Measurement (PM)

External Peer Review Program (EPRP)VII

August 8, 2024

Contents

1.0 BACKGROUND

2.0 APPLICABLE DOCUMENTS

3.0 SCOPE OF WORK

4.1 PERFORMANCE PERIOD

4.2 PLACE OF PERFORMANCE

4.3 TRAVEL

5.0 SPECIFIC TASKS AND DELIVERABLES

5.1 Task 1- Preparation for Data Collection

5.2 Task 2- Data Collection

5.3 Task 3- DATABASE

5.4 Task 4- Data Reporting

5.5 Task 5- Quality Assurance Programs:

5.6 TASK 6- Communications:

5.7 Task 7 - Analysis

5.8 Task 8 - Annual Summary Report

5.9 Task 9 - Training and Education

5.10 TASK 10 –ELECTRONIC QUALITY MEASURES ECQM Development (OPTIONAL) 22

5.11 TASK 11 - EHR transition validation

5.12 Task 12 - Measure Coordination (Optional)

5.13 SCHEDULE FOR DELIVERABLES

5.14 Contractor Personnel

6.0 GENERAL REQUIREMENTS

6.1 ENTERPRISE AND IT FRAMEWORK

6.2 POSITION/TASK RISK DESIGNATION LEVEL(S) AND CONTRACTOR PERSONNEL

SECURITY REQUIREMENTS

6.3 METHOD AND DISTRIBUTION OF DELIVERABLES

6.4 PERFORMANCE METRICS

6.5 FACILITY/RESOURCE PROVISIONS

6.6 GOVERNMENT FURNISHED PROPERTY

ADDENDUM A

ADDENDUM B

ADDENDUM C

1.0 BACKGROUND

The mission of the Department of Veterans Affairs (VA), Office of Performance Measurement (API-PM) within the Office of Analytics and Performance Improvement 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, API-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.

API-PM serves as a vehicle for effecting change in a balanced fashion. Through measurement development, review, analysis and monitoring the quality of care, API-PM:

• Supports transparency for VHA’s initiative to publicly report data.

• Measures Improvements in Health Outcomes.

• Identifies opportunities for improvement, ensuring the highest quality of care for Veterans.

• Provides 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 (EPRP) 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 the transition to Oracle Health 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 must 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. The EPRP program will also support key initiatives in the federal measurement space including Promoting Interoperability and standards adoption

(HL7/FHIR).

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 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. FIPS Pub 200, Minimum Security Requirements for Federal Information and

Information Systems, March 2016

4. FIPS Pub 201-2, “Personal Identity Verification of Federal Employees and

Contractors,” August 2013

5. VA Handbook 0710, Personnel Security and Suitability Program, May 2, 2016, https://www.va.gov/vapubs/index.cfm

6. VA Directive and Handbook 6102, “Internet/Intranet Services,” August 5, 2019

7. NIST SP 800-66 Rev. 1, An Introductory Resource Guide for Implementing the

Health Insurance Portability and Accountability Act (HIPAA) Security Rule, October 2008

8. VA Directive 6500, “VA Cybersecurity Program,” January 24, 2019

9. VA Handbook 6500, “Risk Management Framework for VA Information Systems

– Tier 3: VA Information Security Program,” March 10, 2015

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

11. VA Handbook 6500.5, “Incorporating Security and Privacy into the System Development Lifecycle”, March 22, 2010

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

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

14. VA Handbook 6500.11, “VA Firewall Configuration”, August 22, 2017

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

16. VA Directive and Handbook 6513, “Secure External Connections”, October 12,

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

18. NIST SP 800-37 Rev 1, Risk Management Framework for Information Systems and Organizations: A System Life Cycle Approach for Security and Privacy, December 2018

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

20. Trusted Internet Connections (TIC) Reference Architecture Document, Version 2.2, Federal Interagency Technical Reference Architectures, Department of Homeland Security, June 19, 2017, https://www.cisa.gov/ https://www.va.gov/vapubs/index.cfm https://www.cisa.gov/

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

22. COVID-19 Pandemic Response, Laboratory Data Reporting: Coronavirus Aid, Relief, and Economic Security (CARES) Act Section 18115, June 4, 2020

3.0 SCOPE OF WORK

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 primarily utilize the electronic health record system, which may vary depending on VHA facility. This includes reviewing remote data via the Joint Legacy Viewer (JLV) or similar software in place 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 with The Department of Defense/Defense Health Agency (DoD/DHA). The Contractor will work collaboratively with API-PM through the Contracting Officer or designee 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, validation, maintenance, and oversight 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. Existing measure maintenance and oversight involves routine updates of measure specifications, ensuring measure results are available in reports and resources, and providing information to program offices and stakeholders on measure details and results.

The Contractor will test and prepare tools to transform VHA data collection from abstraction to extraction. This work will occur within the existing EHRs 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.

The Contractor will have the capability to independently perform sampling and weighting as necessary using VHA data sources to produce cohorts for studies, registries and/or reports as directed by API-PM.

Contractor performance will commence within thirty (30) calendar days of contract effective date. Initial abstraction must be completed within thirty (30) calendar days of receipt of first pull list after award date.

4.1 PERFORMANCE PERIOD

The award will include an initial 2-month onboarding period followed by a period of performance which includes a twelve (12) month base year plus four (4) 1-year option periods. Reference PWS Section 6.0 for requirements related to the 2-month onboarding period, including, but not limited to background checks and access to IT systems/network.

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

The eleven (11) Federal holidays set by law (USC Title 5 Section 6103) that VHA follows:

Under current definitions, five are set by date:

New Year's Day January 1 Independence Day July 4 Veterans Day November 11 Christmas Day December 25 Juneteenth Independence Day June 19

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:

Martin Luther King's Birthday Third Monday in January Washington's Birthday Third Monday in February Memorial Day Last Monday in May Labor Day First Monday in September Columbus Day Second Monday in October Thanksgiving Fourth Thursday in November

4.2 PLACE OF PERFORMANCE

Tasks under this PWS will be performed at Contractor facility OR other location as approved by the Government PM, and contracting office.

4.3 TRAVEL

The Government anticipates minimal travel under this effort to perform the associated tasks. The Government will only reimburse travel as deemed necessary by the VHA COR/PM. This will extend to Regional Managers at the discretion of the VHA COR/PM.

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.

Allowable travel and per diem charges governed by FAR Part 31, and the Federal Travel Regulations (FRT) are handled as a direct reimbursable by the agency and will be priced on a fixed price, not to exceed (NTE) line item. Contractor travel within the local commuting area will not be reimbursed. 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. (Reference ATTACHMENT B- Travel Authorization)

The Contractor’s invoice must 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. The Government also expects the Contractor to minimize travel costs where possible.

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 the electronic medical record to measure the identified indicators of healthcare quality. Data that is part of the official medical record will be used. In preparation for data collection the Contractor will be responsible to develop/update measure specifications. The Contractor shall develop measure specifications for all EPRP related VHA Performance Measures.

These measure specifications will be included in electronic Technical Manual (eTM) on the API-PM website and will 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 API-PM.

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.

Measure Specifications- development and revision Measure specifications include 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 (e,g,., National Committee for Quality Assurance (NCQA) or National Quality Forum (NQF) measures, specialized measures to support VHA program office requirements, and e-measurement studies. The Contractor shall keep API-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.

Documentation requirements

The Contractor shall provide API-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 will 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 API-PM and the Contractor. (Reference ATTACHMENT C – Sample Algorithm and ATTACHMENT D – Sample Instrument)

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 API-PM in both algorithmic and textual form. Computerized scoring algorithms will 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 must be provided electronically in a form acceptable with API-PM.

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 (such as data element flags) as determined by API-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 Contractors/sub-Contractors will 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 will be provided simultaneously to the API-PM and may be disseminated to VHA if determined necessary by API-PM. 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.

Specifications for a new tool or significant change (a change that would impact the measure specification population, or adding a question or question option) 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

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

Deliverable 1.1B 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.

TASK 1.2 Technical Specification Revision (Quarterly) The Contractor shall provide revisions/modifications to the technical specifications including data set questions and algorithms as determined by API-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 API-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 NQF) measures as they become available. Major updates or revisions occur every six months (TJC) and annually for NCQA; however, quarterly updates will occur as needed between the major revisions.

• 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 NQF) 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 provide dataset questions quarterly (in advance of their implementation) to identify all the data to be gathered in the review process. All Contractors/sub-Contractors (including abstractors) 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 API-PM.

Deliverable 1.2 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 will 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.

5.2 TASK 2- DATA COLLECTION

The abstraction/review (data collection process) performed for this contract are at present retrospective and consist primarily of electronic record review. The monthly sampling for review will include specialized focused studies and testing and data validation of e-measures and or EHR transition. The plan for the first-year cycle will include abstracting up to 525,000 records to determine the quality of prevention services, acute care and chronic disease management.

TASK 2.1 Conduct monthly record abstraction/review: API-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, which are identified by a control number.

The Contractor shall download the pull list into an electronic database and provide a list to each VHA facility as identified. (Reference ATTACHMENT A – FY24 Facilities List)

The timing of communication of the pull lists to the facilities/EPRP liaisons will be determined collaboratively between the Contractor and the PM. The pull lists will be transmitted 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 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/review data from the medical records using only VHA approved access methods and inside of VHA firewall (remotely using Cisco Anyconnect, RESCUE, or other approved VHA Virtual Private Network (VPN)) connections. Information located after the publication of the pull list will not be included in abstraction. The Contractor shall only accept information that is documented in the permanent medical record in text or checklist format. Some documentation may be found in supplemental electronic tools such as Joint Legacy Viewer (JLV). Documentation must 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 should 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.

The contractor shall only use devices, including portable, that are properly secured with VHA encryption. All devices used for this contract shall not be used for any other purpose, and may need to be upgraded as EHR evolves. This may include requiring dual access and potentially additional hardware and software as the integrated EHR transitions. Any equipment utilized for this contract will be made available for random audits of compliance with VHA security requirement.

• Provide the facility with a list of all data for each record reviewed. The list shall clearly identify data that was not accessible, including data that could not be found in the electronic medical record and/or potentially “failing” cases (e.g. the Data Accountability Checklist (DAC) shall identify 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. DAC format must include a locked official version that cannot be modified (typically a PDF) as well as a version that can be utilized for facility analytics (e.g., Excel file). 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. All changes will be made and incorporated prior to the final Exit Conference.

• Conduct an EXIT conference: Monthly abstractor remote review with the facility includes the following:

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 format of the Exit Conference should be a collaborative task between the EPRP Liaison and the EPRP Abstractor. EPRP Abstractors are trained to provide helpful insights in understanding the measures and data that can assist facilities in identifying areas of improvement opportunity.

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:

o Changes to existing questions and rules o New measures o Discontinued measures o Changes to measure Scoring Algorithm o 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

- 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 EPRP Liaison feels a change is needed, the liaison 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 the Contractor’s supervisory personnel, typically a Regional Manager (RM) position. If there are any unresolved issues the RM shall elevate the issue to the Contractor’s next higher level of authority, typically a Director of Field Operations who will discuss with the COR/PM as needed. The RM may be included at the Exit Conferences at the discretion of the Field Director (and COR/PM if travel is involved) to better orient or provide more in-depth review or assist on resolving issues.

Abstractors and EPRP liaisons shall determine a mutually agreeable time and method for DAC review and Exit Conferences.

Abstraction shall take place during normal business hours if 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 are acceptable forms of performing the Exit unless otherwise arranged with PM approval.

Deliverable 2.1 Record Review (includes DAC format and Exit Report) Record reviews shall be completed as outlined in the plan. Contractor shall start record abstraction within thirty (30) calendar days of contract award. First abstraction must be completed within thirty (30) calendar days of receipt of first pull list once the contract is awarded. Each monthly case list must be completed within thirty (30) calendar days of issue.

On completion and finalization of data an Exit Report will be provided. This report will include a summary of data for each measure for each sample. The report shall include: Facility number; date of sample; data interval collected; Exit Conference date; Measure mnemonic; measure name and description; as well as numerator and denominator totals for discharges before January 1 of year and after January 1 of the year; quarter to date and year to date scores. First Exit reports are due within thirty

(30) calendar days of receipt of first pull list once the contract is awarded. Each monthly case list must be completed within thirty (30) calendar days of issue.

TASK 2.2 Reconsideration process.

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: Abstractor cannot change the data once the Exit Conference has started. 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 Contractor will 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.

• Accountability (National Indicator) measures are eligible for reconsideration.

API-PM will provide a list of Accountability measures to the Contractor. These measures are subject to a change in status at any time.

• Additional measures may be eligible for reconsideration, API-PM shall determine measure eligibility for reconsideration and notify the Contractor.

• The reconsideration process starts with an initial review of case in question.

• Initial review of each reconsideration case 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.

• The Contractor reviews all accepted reconsideration cases and determines if the data provided meets the specification for compliance as outlined in the VHA Technical Manual. The Contractor discusses 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 provides (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 also outlines 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 is forwarded to VHA COR/PM for a final decision.

Deliverable 2.2A. Reconsideration Database Process Tool 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.

The Contractor shall develop a secure web-based reconsideration database system for submission and processing of post exit conference reconsideration requests. The system shall allow facility liaisons to electronically submit reconsideration requests and supporting information. The system must meet all VHA privacy and security requirements. The system shall store reconsideration data for the life of the contract, be accessible to API-PM staff, and provide the capacity to generate reports for tracking reconsideration activity. The secure web-based reconsideration database system will have the capability to generate or provide reports accessible to API-PM staff to review reconsideration cases by measure, fiscal year, facility name and number, Exit date, date of requested reconsideration, measure group, control number, issue description, review remarks, and outcome of the review (data change/no change).

Deliverable 2.2B Quarterly Review and Revision of Reconsideration Database Process Tool. Contractor shall review and update the web-based tool in collaboration with the API-PM office. Updates to the system shall be made quarterly.

5.3 TASK 3- DATABASE

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 website 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. The Contractor shall develop a plan for the transmission of the abstracted data and transmit the abstracted data, including quality control steps, transmission plans for facilities and for submission of data to API-PM. The Contractor shall provide API-PM the data (raw and scored) per agreed to daily, monthly, and quarterly transmission as scheduled. Data shall be loaded onto a shared drive in the format outlined in the Data Requirements. If there are changes to the data based on errors in data collection instruments or due to abstraction, these changes shall be made/re-abstracted and new data uploaded in the quarter at no additional charge to the government. Changes to the data may occur and shall be accepted as facilities identify documentation retrieved after completion of the abstraction process.

TASK 3.1 Data Transmission: Secure daily, monthly, and quarterly transmission of data at the facility, VISN and National levels. Additionally, data maybe requested as needed. The Contractor shall:

• Aggregate data from record abstraction to assess performance at the national, VISN and facility levels. These scores will be calculated and delivered as required by the

Technical Specifications document (e.g., aggregated at VISN and national level and using facility weights).

• Collect demographic data that will support risk adjustment as requested.

• Generate daily and monthly facility specific reports to provide an immediate feedback loop of quality related information and data to the facility.

• The Contractor shall provide abstracted scored and un-scored (raw) data to API-PM on a daily, monthly, and quarterly basis by 8:00 am EST on the agreed upon date for each time-period.

• The data files containing the elements from each abstracted record, both in the final quarterly file or the monthly file, shall be provided in a Statistical Analysis System (SAS) formatted file. The SAS file format may be in SAS transport format or in a file format compatible with the current version being used by VHA. All numeric fields shall be stored as numeric variables; date fields must be stored in the SAS date format; time fields must be stored in SAS time format. The Contractor shall provide a short single phrase SAS label describing the business nature of the variable/translation of the item mnemonic (e.g., variable = dochospce, label=documented terminal illness). Data shall be transmitted via the Internet using a style of encryption that ensures the security of the data. Specifically, the data encryption/transmission must be made using VeriSign Class 2 or the current security software being used by VHA at the time of transmission.

Upon completion of the contract and at the discretion of the government, the Contractor shall return or destroy all data and files, including temporary files that may be created as a part of the review and analysis process and in the SAS files for all collected data elements.

Deliverable 3.1 Daily data transmission The Contractor shall prepare data files incorporating the data elements from each record abstracted, results of each scored quality measure and scoring specifications addressing the conditions required for specific data elements to satisfy the scored performance. Results (raw and scored), in Excel Format or SAS unless specified otherwise, and scoring/ measure specifications shall be provided to the designee (COR/PM) daily.

Deliverable 3.2 Monthly data transmission The Contractor shall prepare data files incorporating the data elements from each record abstracted, results of each scored quality measure and scoring specifications addressing the conditions required for specific data elements to satisfy the scored performance. Results (raw and scored), in Excel Format or SAS unless specified otherwise, and scoring/ measure specifications shall be provided to the designee (COR/PM) monthly (within fifteen (15) business days of month’s end). First transmission shall be completed within fifteen (15) calendar days of completion of first pull list once contract is awarded.

Deliverable 3.3 Quarterly data transmission The Contractor shall prepare data files incorporating the data elements from each record abstracted, results of each scored quality measure and scoring specifications addressing the conditions required for specific data elements to satisfy the scored performance. Results (raw and scored), in Excel Format or SAS unless specified otherwise, and scoring/ measure specifications shall be provided to the designee (COR/PM) quarterly within fifteen (15) business days after the end of each quarter.

5.4 TASK 4- DATA REPORTING

The data abstracted shall be used to generate information for population-based or pattern analysis through various levels of data aggregation. The Contractor shall provide raw and scored data to VHA at the facility, VISN and National levels.

TASK 4.1 Report Preparation /Distribution: 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.

The Contractor has the specific role of providing results to facilities per the specifications and deliverables outlined below.

In reporting the data collected, the Contractor shall develop processes for:

• Providing facilities with an immediate report of findings (this includes a daily uploading of data) at completion of the facilities’ monthly review.

• Ensuring an exchange of raw and scored data at the data element and question level with drill down capabilities using innovative technologies and methods provided by or sanctioned by API-PM to ensure systematic quality assurance. (e.g., delivery of raw and scored data in XML format to an API-PM -hosted Secure Sockets Layer (SSL)-encrypted web service to be validated against a published schema); providing API-PM with raw and scored data daily and monthly utilizing a secure method of data transmission. Scored data are patient and measure level results. The scored data shall contain identifiers for the patient, facility, VHA network and key dates such a study month or admission/discharge dates and values for each measure or indicator (called “flags’) identifying whether the measure or indicator was successfully completed for the specific patient (case).

• Providing API-PM with raw and scored data quarterly after data changes have been made following field requests for review of findings based on chart reviews that may take place through the “Reconsideration Process.

• The format for the reports shall be determined by API-PM and shall be finalized with the Contractor within fourteen (14) calendar days following the award of the contract.

The Contractor shall prepare data files incorporating the data elements from each record abstracted, results of each scored quality measure or supporting indicator (not yet determined to be a quality measure) and scoring specifications addressing the conditions required for specific data elements to satisfy the scored performance. Results (raw and scored), in Excel Format or SAS unless specified otherwise, and scoring/ measure specifications shall be provided to the designee (COR/PM) on a monthly and quarterly basis, at an agreed to date. The Contractor shall provide abstracted scored and un-scored (raw) data to API-PM on a daily, monthly, and quarterly basis by 8:00 am EST on the agreed upon date for each time-period.

• The data files containing the elements from each abstracted record, both in the final quarterly file or the monthly file, shall be provided in a SAS formatted file. The SAS file format may be in SAS transport format or in a file format compatible with the current version being used by VHA. All numeric files must be stored as numeric variables; date fields must be stored in the SAS date format; time fields must be stored in SAS time format. Data shall be transmitted via the Internet using a style of encryption that ensures the security of the data. Specifically, the data encryption/transmission must be made using VeriSign Class 2 or the current security software being used by VHA at the time of transmission. Upon completion of the contract and at the discretion of the government, the Contractor shall return or destroy all data and files, including temporary files that may be created as a part of the review and analysis process.

• In the SAS files for all collected data elements, the Contractor shall provide a short single phrase SAS label describing the business nature of the variable/translation of the item mnemonic (e.g., variable = dochospce, label=documented terminal illness).

• The Contractor shall be available to resolve result discrepancies in the data validation process from the date of data delivery to the end of the resolution for all business days.

The Contractor shall be able to provide cumulative results within any performance year.

Deliverable 4.1 Monthly Data Report The Contractor shall provide monthly reports of performance on each measure in the approved technical specifications. The formats for the reports shall be submitted in draft by the Contractor within fourteen (14) calendar days of award and finalized within fifteen (15) calendar days following approval by the COR/PM. The first monthly report shall be published not later than forty-five (45) calendar days of contract award and fifteen (15) business days of each month in accordance with the schedule provided by the COR/PM. The monthly reports shall include data aggregated at the facility, VISN and national levels and shall include minimum and maximum range information as well as the number of cases that were included in each calculation at each level of aggregation.

Deliverable 4.2 External Data Report The Contractor shall provide to API-PM in accordance with external accrediting bodies (i.e., TJC or CARF) and/or community standards organizations (i.e., NCQA or NQS measures) required data in a patient level identifiable form (for example, control number) allowing API-PM to report the correct data points to accrediting body on schedule. This data may be identified by the accrediting body’s mnemonics initially or may be cross walked to Contractor development data point mnemonics.

The Contractor shall develop a Missing Data Report pertaining to that data and shall provide to the facilities monthly at the time of the Exit. The format for the report shall be submitted in draft by the Contractor to API-PM within fourteen (14) calendar days of award and finalized within fourteen (14) calendar days following approval by the COR/PM. A Missing Data Report to external accrediting bodies (i.e., The Joint Commission or Commission on Accreditation of Rehabilitation Facilities (CARF)) and community standards (i.e., NCQA or NQS measures) shall be provided to the facilities each month. First report must be completed within forty-five (45) calendar days of contract award and monthly, within thirty (30) calendars days of the pull list release.

5.5 TASK 5- QUALITY ASSURANCE PROGRAMS:

Develop, implement, and maintain an internal (abstraction related) quality assurance (QC) program to ensure a strong data reliability process that includes assessment of accuracy of abstractors and inter-rater reliability (IRR) of the abstraction tools, as approved by the

API-PM.

TASK 5.1 Quarterly QC /IRR report The Contractor shall establish a program/methodology for detecting and correcting data problems and for monitoring data security and privacy. By establishing and maintaining a scientifically rigorous, continuous quality improvement approach to monitoring and evaluating the validity and reliability of abstracted data, The Contractor shall assure precision and accuracy of medical record abstractions and the data it produces. At a minimum, these methods shall include techniques for detecting irregularities in abstracted data. The Contractor should propose a system for Quality Control of data for abstraction, monitoring, data security and privacy. This plan shall include the Contractor’s plan for identification of problems with abstraction and or specific abstractor. Any data abstraction problems identified, as a result of error or failure in Quality Control program, shall result in re-abstraction at no cost to VHA, if requested by COR/PM. The Contractor shall propose an ongoing monitor for Quality Control. This plan shall include a proposed minimum number of cases of random re-abstraction per abstractor per quarter; include the minimum threshold, and the consequence(s) for not meeting the threshold. The Contractor shall establish a comprehensive model and tracking system to assure the accuracy of the data processing system and the accuracy and timeliness of data and reports. Delivery of data to API-PM in a timely fashion is essential.

Deliverable 5.1- Quarterly Quality Report The Contractor shall provide quarterly reports of performance on each measure in the approved technical specifications. Contractor data analysts are to be continuously available from delivery of scheduled results through resolution of all discrepancies. The first quarterly report shall be published twenty (20) calendar days after the end of first quarter and within fifteen (15) business days of the quarter’s end thereafter in accordance with the schedule provided by the COR/PM.

The quarterly and annual reports shall include data aggregated at the facility, VISN and national levels and shall include minimum and maximum range information as well as the number of cases that were included in each calculation at each level of aggregation.

The Contractor shall provide complete reports describing quality control results for each quarter, including statistical analysis, identified weaknesses and actions taken to include follow-up action reports. The report is due within fifteen (15) calendar days after the first 3 months of data collection and quarterly (within fifteen (15) business days after quarter ends) thereafter.

5.6 TASK 6- COMMUNICATIONS:

Meetings between API-PM and the Contractor shall be either face-to-face or the computer/phone conference format. Expectation is for bi-weekly meetings to assess status with minutes provided within 5 days of meeting. Monthly reports shall be in an approved format and shall be submitted for approval of the COR/PM. Daily communication is expected between Contractor and COR/PM. Periodic planning meetings minutes are due within 5 days.

Deliverable 6.1 Bi-weekly (Every two weeks) Meeting Report The Contractor shall submit minutes describing the status and projected status for the work. The Biweekly report is due within five (5) days after each meeting.

Deliverable 6.2 Monthly Progress Report The Contractor shall submit monthly progress reports describing the projected status for the work completed. The Monthly report shall also include percent of pull list completed and billed and non-reviewed records, and the number of reviews remaining separated for both fiscal year and the contract anniversary year. The format for the Monthly report shall be submitted in draft by the Contractor within fourteen (14) calendar days of award and finalized within fourteen (14) calendar days following approval by the COR/PM. The Monthly report is due twenty (20) calendar days after the end of the 30-day reporting period. The Monthly Report must be included with the monthly invoice and shall be used to verify payment.

5.7 TASK 7 - ANALYSIS

The Contractor shall provide analyses utilizing the data gathered under the contract or data available in VHA corporate data systems. The topics of these analyses shall be determined based upon the analysis and validation of the data and the needs of VHA and agreed to by the Contractor. At a minimum the analyses shall explain the methodology, summarize results, and reference literature citation of clinical studies for comparison of VHA with the private and public sectors, if applicable. Types of analysis may include projects where the contractor will need to perform sampling, analysis, and reporting work directly with VHA data systems. The Contractor must have the technical capability using programming languages such as SAS and SQL to perform sampling and weighting as necessary to deliver reliable and valid results. The contractor and API-PM shall work collaboratively to establish the project scope and milestones.

Deliverable 7.1 Analyses Analyses shall be due as agreed to during the project scoping discussions by the Contractor and API-PM and may vary. The contractor must have the ability (surge capacity) for rapid response in situations where VHA priorities require swift action.

Analyses can utilize existing tools or external specifications and algorithms; may include new tool development or significant change to existing tools; be used for validation and gap analysis for eCQM and EHR transition tasks, or other tasks to support VHA program office goals and objectives.

5.8 TASK 8 - ANNUAL SUMMARY REPORT

The Contractor shall design and conduct an annual report that shall generate continuing feedback and ongoing information about important aspects of external peer review program to understand program issues and evolving customer needs while improving the program operation and cost.