The National Renal Administrators Association (NRAA) and the Centers for Medicare & Medicaid Services (CMS) are testing an approach that would allow small and medium dialysis organizations to avoid the manual submission requirement for CMS' CROWNWeb (Consolidated Renal Operations in a Web-Enabled Network) data-collection system.
The NRAA's Health Information Exchange (HIE), which enables the retrieval of data from a facility's electronic medical record (EMR), was developed to address a disparity in CROWNWeb's submission requirements: While the three large dialysis organizations (LDOs) could submit data in batches to the Web-based system, small and medium providers were not given this opportunity.
"We believe that there is a large segment of that market who have capabilities of current EMR providers that could actually do something with CROWNWeb data, similar to a batch-submitting organization, but was not given the opportunity from the get-go," said Marc Chow, MS, NRAA Executive Director.
"The manual option was laid out, and so was the one where large dialysis organizations were able to batch submit. That's where we fought hard to say this is potentially not the only situation."
The manual submission process can be arduous and vulnerable to error.
"The positives of the HIE are straightforward," Mr. Chow said, adding that the manual process still will be a viable option that many facilities will choose or have to use.
"The HIE is time-saving, which has associated cost advantages. You have a significant improvement in data accuracy because it's coming out of a clinical system—no double keying or keying errors. You are getting data in a more timely manner, which is an advantage.
"The other advantage is you get automated feedback upon the acceptance of the file of any errors that CROWNWeb may produce."
Successes and Challenges
The Phase III CROWNWeb demonstration pilot, which began in January, features all three options for data submission: manual, or single use; batch for LDOs DaVita, Fresenius Medical Care North America, and Dialysis Clinic Inc.; and the Health Information Exchange.
"Our goal is to get the data in the least burdensome way to the provider," said Jean D. Moody-Williams, RN, MPP, Director of the Quality Improvement Group at CMS.
"We believe this can best be accomplished by having multiple submissions of data—single use and batch. This [HIE] is one of several ways that providers and facilities would be able to submit their data, and it would be up to providers to judge which method best meets their business needs."
The pilot, which in March was extended through April 20, has provided important information.
"The whole purpose is to add users, see capacity, and learn the things that we must improve, so from that perspective we would consider the pilot a great success," Ms. Moody-Williams said.
Debbra M. Hattery, RN, MS, Director of Information Systems at CMS, provided some statistics on the pilot during a March 16th phone interview.
"We have had close to 17,000 patient records updated, and we've added 1,800 new patients into the system during this period," she said. "The pilot has shown us that we can successfully implement a clinical application integrated with an identity management system. That's been quite a success and one of the positives.
"Where we have had some mixed success during the pilot is the upload of batch files. We have had 800 or a little more successful uploads, and at the same time around 50 unsuccessful attempts to upload. Until we can get that to where we have 100 percent successful batch upload, we will still work on infrastructure support to allow this."
The National Renal Administrators Association also experienced challenges.
"We encountered various technological issues but resolved those issues and submitted live patient data into CMS' CROWNWeb system," said Howard Thomas, Project Director for NRAA's Health Information Exchange.
In order to prepare for the national rollout of CROWNWeb, the NRAA is spending a period of time correcting problems they experienced in the trial, evaluating data submitted to CMS, and identifying any errors in the reports.
"We continue to work with additional EMR vendors to get their data set certified so that they can participate in a national rollout," Mr. Thomas said.
"NRAA is setting up an online registration portal so facilities can come in and automatically register and get themselves set up with the HIE. That way, we can take system adoption to a higher and faster level."
As of April 2nd, four vendors had been certified, and another three to four were close.
‘Level Playing Field’
Only those facilities with paper-based records should be manually entering data, said Joyce Jackson, MHA, President and CEO of Northwest Kidney Centers.
"I've been pretty involved in the NRAA network to dialogue with CMS to let them know that there are many dialysis facilities that have EMR and are capable of electronically transmitting data, avoiding the manual entry, which is laborious and subject to error. Any facility using contemporary EMRs should have capability of transmitting data to CMS."
There are multiple advantages to employing this type of data-submission approach, noted Jay Wish, MD, Professor of Medicine at Case Western Reserve University School of Medicine and Medical Director of the Dialysis Program at University Hospitals Case Medical Center.
"To be perfectly honest and frank, this was somewhat unfair of CMS to give a competitive advantage to the larger dialysis organizations because they won't have the labor requirements of all of this manual data input that smaller facilities were going to be forced to have under the original plan," he said.
"The data exchanges through NRAA are not only desirable in terms of maintaining accuracy and efficiency of data input but also essential in order to keep the other providers competitive. This levels the playing field."
CROWNWeb itself also could offer improvements, provided it lives up to its potential, Dr. Wish mentioned.
"In theory, CROWNWeb is a system whose time has come," he said. "This is the way health care is moving, and the more electronic and meaningful use characteristics that these data systems have, the users will benefit."