The Validation & Improvement Dashboard can be accessed from the Hospital menu by navigating to Hospital → Reporting→ Validation & Improvement Dashboard
Data Refresh Status:
This widget informs the user, at a glance, whether the data is current based on their specific data refresh schedule. For clients refreshing data On Demand, this widget will not appear.
The user can click on the widget to view their Clinical Quality Advisor's contact information.
Use case: An incomplete or past due Data Refresh may have one or more of the following implications:
- EncorE is missing patient discharges for one or more days depending on the last successful data refresh.
- Changes to mapping or patient data (coding, diagnoses etc.) made since the last successful refresh are not being evaluated.
- In the case of an individual load failure, certain data elements may not be evaluated at all (i.e., labs, diagnoses, orders etc.).
Supplemental Data Elements (SDE):
This widget informs the user at a glance of the completeness of the supplemental data elements.
Green Icon: Indicates that 100% of the Encounters have the data element documented.
Yellow Icon: Indicates that 15% or less of the Encounters are missing the data element.
Red Icon: Indicates that more than 15% of the Encounters are missing the data element.
The user can click on the widget to view the detailed Discharges & Supplemental Data report that identifies the patients missing those elements.
A user can filter by the submission quarter, then select the measures of their choice by holding CTL and clicking on each measure of their choosing. The Supplemental Data Element (SDE) detail report will update with your selections upon clicking the green 'Update' button.
Click the + next to the SDE to expand, then click the + next to the 'Missing' header to view the patients missing that SDE.
Use case: Supplemental data is evaluated for every patient and may be used for risk adjustment or population health analytics. There is no penalty for missing SDEs.
Patient Discharges:
This widget displays YTD discharges per day for the selected date range. For clients refreshing data On Demand, this widget will not appear.
The user can click on the widget to view the Discharges & Supplemental Data detail reports.
To see results related to all eCQMs - Select All.
To see results related to a specific eCQM - Select that eCQM.
Click Update
Clicking on the hyperlinked Total Discharges will bring the user to a detailed Discharges report that shows discharges/day as well as the % Change in discharges from the previous day.
Value Set Quality Check:
This widget displays the total number of value sets associated with the Eligible Hospital's active eCQMs, as well as the completeness of those value sets as it relates to the proportion of value sets that contain a code associated with at least 1 patient encounter included in the measures.
- Green Icon: Indicates that 100% of the Value Sets include at least one qualifying patient encounter associated with a code in that value set.
- Yellow Icon: Indicates that up to 15% of the Value Sets do not include at least one qualifying patient encounter associated with a code in that value set.
- Red Icon: Indicates that more than 15% of the Value Sets do not include at least one qualifying patient encounter associated with a code in that value set.
Note: It is expected that not all Value Sets will have an associated qualifying patient encounter with a code from the value set. For example, OB and VTE diagnosis value sets are used to exclude patients from the IPP for VTE 1 and VTE 2, so patients with those codes would not be included in the VTE measure.
The user can click on the widget to display the enhanced Value Set Quality Check (VSQC) report.
The initial report view displays all OIDs associated with the Eligible Hospital's active eCQMs along with the OID description, type, number of codes in the value set, number of patients associated with a code in the value set, % of total patients with the code, and the CMS IDs that reference the value set. The user can click on the plus sign next to the OID of their choosing.
Clicking on the plus sign to the left of an OID will display a list of patients associated with one or more codes in the value set. All patients listed are included in the population of at least one of the EH's active measures.
Users can filter the Value Set Quality Check by date range as well as by measure. Selecting a measure from the Measure Selection drop down will limit the report to display only value sets associated with the selected measure.
Use cases for the Value Set Quality Check report:
- Measure Validation - VSQC enables a user to filter by measure and confirm that encounters are being brought in with codes in the corresponding value sets. For example, when implementing the Opioid measure a user can view the VSQC to confirm that there are patients with Palliative Care documented. Furthermore, they can access the patients listed under the Palliative Care value set to confirm that they are appropriately qualifying as a Denominator Exclusion for the Opioid measure.
- Mapping Validation - Clients can leverage VSQC to confirm that data elements are mapped correctly. This will be especially helpful after the annual measure specification updates so a user can confirm all mapping changes have been addressed. Users can also leverage this report to confirm data elements are being captured appropriately after a change in workflow and/or method of documentation.
Invalid Units:
Units are important for some eCQMs. The invalid units report helps to identify data that contains invalid or missing units for specific data elements. This report is not filtered by date range or measure.
