Task Team Meeting - Rolling Agenda and Minutes 2018

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Database Task Group Meeting December 20, 2017

  • Present: Allan, Con, Julie, Tina
  • Absent: Laura, Trish
  • Minutes prepared by: AG
  • Action items in BOLD

1. Follow-up on seeking eChart access for coder. Allan reported that after talking to a high-level administrator at Manitoba Health, that indeed we are not going to be allowed to get eChart access.

2. Regarding influenza coding. After a discussion we agreed on the following aspects of coding:

  • Unrelated to ICD-10, we will continue to record whether:
    • A lab test for influenza was done and whether it was positive or negative. If more than one test was done (at different times, or by different labs), it is considered positive during flu season IF ANY of them are reported as positive. Off of flu season it’s considered as positive only if the FINAL CADHAM result was positive (e.g. off of flu season flu tests done by the separate hospital labs are ignored).
    • Whether a “full course” of treatment was given for influenza. The usual course of oseltamivir (Tamiflu) is 5 days. But WHO and CDC recommend that in severe cases the drug should be continued until the infection is resolved or there is satisfactory clinical improvement.
  • Based on this, ICD-10 coding for influenza will be done as follows:
    • Use this website https://www.gov.mb.ca/health/publichealth/surveillance/influenza/index.html to iIdentify whether we’re in flu season or not.
    • During established flu season a person will be considered to have influenza if either of the following is true: (i) any lab test done for influenza was positive, or (ii) the patient was believed the the medical team to have influenza and given a full course of treatment (which could possibly have concluded after leaving the hospital).
    • Off flu season (before there is any reported flu in the province, and after the flu season has been declared to be over) a person can ONLY be diagnosed as having influenza if the FINAL CADHAM test result is positive. In the absence of such a final Cadham result, clinical suspicion, treatment for flu, and positive rapid tests will be considered as NOT INFLUENZA.
  • Allan put all this info into the wiki article called “Influenza in ICD10” -- done.

3. Further discussion of the ICD10 diagnosis of Palliative care.

  • We agreed to operationalize using the ICD10 code of Palliative care as any of the following 4 items:
    • 1. ACP-C status
    • 2. Had been on palliative care ‘’prior’’ to this hospital admission (i.e. at home or in the care facility)
    • 3. Is receiving active palliation. What is meant by this is (again) related to the intent of care --- so receiving aggressive symptom control measures (e.g. a morphine drip) does not consitute active palliation UNLESS the intent of the overall care at this point is control of symptoms and not cure or even prolongation of life.
    • 4. The Palliative Care Service (physician group) is seeing the patient in an ongoing fashion. This means that they have seen the patient at least twice during this admission, or that they wrote that they intended to follow but the patient died or left hospital before they could be seen a second time. Thus, if that consult team saw the patient in an initial consult but didn’t or didn’t plan to follow them longitudinally, then this item doesn’t apply.
  • Allan will modify the wiki article Palliative care to reflect this -- done.

4. Regarding discharge planning, paneling, etc.

5. Regarding the list of “reasons for CRRT” that is completed by the Nephro team.

  • After discussion, we agreed that whatever they code should find it’s way into our general list of diagnoses.
  • Towards this end, we agreed that that/those code(s) should be duplicated: (a) in the Temp file for the special purpose of identifying why they were on CRRT, and (b) in our general list of diagnoses. Allan will identify the ICD10 code(s) that correspond to those diagnoses used by Nephro for this purpose.

6. Switching over to ICD-10

  • Allan is continuing work on making a set of “quick codes” for both ICD-10 and CCI, that can be chosen as unique entities, to represent procedures that are common, or difficult to otherwise figure out how to code.
  • Regarding the list of acquired complications that previously were singled out to ensure that they were coded: Trish spoke with collectors who indicated that this list is of “high profile” entities that they don’t really think they need reminding about. So, we will bring this information back to the Steering Committee, with a recommendation that there is no need to continue using this list.

7. Regarding CCI.

  • Allan presented a greatly simplified version of CCI chapter 3 (Diagnostic imaging procedures). See new wiki article “Procedure coding in ICD10/CCI” for evolving details.
  • We recognized that for all procedures an option (to be discussed more later) is to allow a “number done” to be associated with each procedure coded for each date. Thus, for example, if 4 CXRs were done on a given day, one would only need to enter it once, but with that count saved with the item (with default being 1). We will discuss this more after we’ve worked through all the chapters of CCI later.
  • We began what will be a series of conversations about WHICH procedures we want to code, and creating guidelines/rules around them. We identified the benefits of simple rules, and the dynamic that goes along with simplicity is that sometimes we will collect procedures that we’re not that interested in. We also agreed that the same rules should apply to ICU and wards. Today we discussed Therapeutic Procedures. In coming meetings we will discuss Diagnostic Procedures. And after all this is done, we must decide whether, in addition to the picklists, to ALSO allow for menu-based coding of other procedures.
  • We agreed that a good goal would be to be able to include all the current items on the Tasks in CCI, and so be able to dispense with the Tasks (HD, PD, trach, isolation, NIV).
  • We still need to clarify isolation. Currently we are recording 3 different levels of isolation, and none of these relate to use of a negative pressure room. Allan will talk to Bojan and Nick to clarify the needs here.

8. Update on seeking data on PHIN validation data, hospitalization data, and mortality data from WRHA.

  • Allan is working on the new PIA.

9. Regarding Sepsis coding. Allan reported that our coding will follow the new Sepsis-3 definitions.

  • This greatly simplifies identification of Septic shock, eliminates SIRS from all sepsis-related definitions, and eliminates what was previously called “sepsis” i.e. SIRS without acute organ failure.
  • For what was previously called “severe sepsis”, the new guidelines merely call “sepsis”, which is identified as acute organ failure caused by proven or presumed infection. The official guidelines operationalize new organ failure as an increase in SOFA score by 2 or more points. Since SOFA scoring is nontrivial, there was concern about whether it is practical for the data collectors to try and do this. It was decided that Laura and some other ICU coders will look at the SOFA scoring grid and we’ll discuss this later.

10. Starting with CLI criteria, there was extensive discussion about the difficulties in adhering to criteria-based diagnoses. *Laura clarified that even more than CLI, VAP requires much checking back and forth at data over time. It was decided that we would like to create wiki-based tools that will make it easier for collectors to do these tasks. The tools would incorporate the diagnosis guidelines into some sort of checklist “machinery”. Trish will assign Laura and a few other coders to work on this.

Next Task Group Meeting: January 4, 2018 at 10:00 am


Database Task Group Meeting December 20, 2017

  • Present: Allan, Con, Julie, Laura, Tina, Trish
  • Absent: none Minutes prepared by: AG Action items in BOLD

1. Follow-up on seeking eChart access for coders

  • Allan and Jodi Walker-Tweed have sent a letter to Christina Van Schindler, the WRHA Chief Privacy Officer, asking for permission. Awaiting a reply.

2. Regarding influenza coding.

  • We had previously discussed two possible categories of influenza: (1) lab-confirmed and (2) suspected. But in further review of IDSA and CDC recommendations, it’s fairly complicated. The value of the tests in helping us figure out whether a person has influenza depends on: (a) how long after onset of symptoms the test was done, (b) whether the sample was upper or lower respiratory, and (c) whether the test is done in the midst of flu season, at the start of flu season, at the end of flu season, or not at all during flu season. Given all of the variation in lab interpretation, the idea of lab-confirmed vs. suspected is not being used.
  • Here is a workable approach:
    • During established flu season (defined as there has been laboratory-confirmed flu in the community), the diagnosis of influenza is mainly clinical. So, lab confirmation of any type is NOT needed to make the diagnosis. If the team says they think it’s flu, and they’re treating with a full course of tamiflu, then take that as true influenza, regardless of the results of any influenza tests, done in hospital labs or Cadham.
    • Completely off flu season (warm months, before there is any reported flu in the province, and after the flu season has been declared to be over) a person can ONLY be diagnosed as having influenza if the FINAL CADHAM test result is positive. In the absence of such a final Cadham result, clinical suspicion, treatment for flu, and positive rapid tests will be considered as NOT INFLUENZA.
    • The hard part is right at the start and end of typical flu season. In this case, use the following algorithm:
      • One or more lab tests were done (including rapid tests in hospital labs, and Cadham tests) and ‘’’any’’’ of them were positive -- then consider influenza to be present.
    • No lab tests were done, but the team says they think it’s flu, and they’re treating with a full course of tamiflu, then take that as influenza being present.
  • Allan put all this info into the wiki article called “Influenza in ICD10” -- done. Everyone is invited to take a look at this.

3. Further discussion of the ICD10 diagnosis of Palliative care.

  • This is different from the Palliative Care Service -- that refers to a group of physicians. Palliative care refers to whether the clinical plan for the patient is to provide comfort towards the end of life, not to prolong life.
  • Per Julie, the way this is being used is for reporting death rates -- specifically to remove people getting Palliative care from the denominator and numerator of death rates.
  • Accordingly, to figure out if a person should have the ICD10 diagnosis of Palliative care, we must figure out the INTENT of care. If the intent is aimed at cure and prolonging life, then the person is not in Palliative care. If the intent is primarily control of symptoms (whether the person currently has symptoms or not) and not cure or even prolongation of life, then the person is in Palliative care.
  • We will operationalize Palliative care as any of the following 4 items:
    • 1. ACP-C status
    • 2. Had been on palliative care ‘’prior’’ to this hospital admission (i.e. at home or in the care facility)
    • 3. Is receiving active palliation. What is meant by this is (again) related to the intent of care --- so receiving aggressive symptom control measures (e.g. a morphine drip) does not consitute active palliation UNLESS the intent of the overall care at this point is control of symptoms and not cure or even prolongation of life.
    • 4. The Palliative Care Service (physician group) is seeing the patient in an ongoing fashion, which means has seen them at least twice during this admission. So, if that consult team saw the patient in an initial consult but isn’t following them longitudinally, then this item doesn’t apply.
  • Allan will modify the wiki article Palliative care to reflect this -- done. Everyone is invited to take a look at this.

4. Regarding discharge planning, paneling, etc.

  • Discussion identified that there are reasons to separately classify time in hospital spent waiting to go to: long-term care facilities, home. Furthermore, with the advent of Riverridge 2, and the transition that is currently taking place in the WRHA to convert the Vic, Conc and Oaks to transition hospitals, there may be a near-future need by the Internal Medicine Program to know about time spent waiting to transfer to those. This all comes up because as of now, we have only a single ICD10 code to cover all of this. In the current database we track these via Temp, but the goal in general is (where possible) to incorporate Temp information into ICD10 and CCI codes.
  • Allan will see how we might do this in ICD10 -- here is a solution created by adapting a set of existing ICD10 codes:

Allan has put these into the Wiki. Everyone is invited to take a look.

5. Regarding the list of “reasons for CRRT” that is completed by the Nephro team.

  • After discussion, we agreed that whatever they code should find it’s way into our general list of diagnoses.
  • Towards this end, we agreed that that/those code(s) should be duplicated: (a) in the Temp file for the special purpose of identifying why they were on CRRT, and (b) in our general list of diagnoses. To operationalize this, Tina will send Allan the Wiki link to this list, and Allan will identify the ICD10 code(s) that correspond to those diagnoses used by Nephro for this purpose.
    • Link was provided and Allan replied in email 2017-11-18; contents integrated into CRRT#ICD10. Further discussion required since some did not have unambiguous equivalencies.

6. Switching over to ICD-10

  • Allan is continuing work on making a set of “quick codes” for both ICD-10 and CCI, that can be chosen as unique entities, to represent procedures that are common, or difficult to otherwise figure out how to code.
  • Regarding the list of acquired complications that previously were singled out to ensure that they were coded: Trish spoke with collectors who indicated that this list is of “high profile” entities that they don’t really think they need reminding about. So, we will bring this information back to the Steering Committee, with a recommendation that there is no need to continue using this list.

7. Regarding CCI.

  • It was agreed that for simplicity & consistency of coding, that for the most common and tricky codes we need a picklist. Allan will work on that.
  • We began what will be a series of conversations about WHICH procedures we want to code, and creating guidelines/rules around them. We identified the benefits of simple rules, and the dynamic that goes along with simplicity is that sometimes we will collect procedures that we’re not that interested in. We also agreed that the same rules should apply to ICU and wards. Today we discussed Therapeutic Procedures. In coming meetings we will discuss Diagnostic Procedures. And after all this is done, we must decide whether, in addition to the picklists, to ALSO allow for menu-based coding of other procedures.
  • We agreed that a good goal would be to be able to include all the current items on the Tasks in CCI, and so be able to dispense with the Tasks (HD, PD, trach, isolation, NIV).
  • After discussion about rules around which Therapeutic Procedures (chapter 1 of CCI) to collect, we came up with:
    • Include all therapeutic procedures done outside the patient’s unit
    • Include all therapeutic procedures done using an endoscope (whether inserted through an orifice, incision or wound)
    • Code the following therapeutic procedures done in the patient’s unit -- but only the FIRST time it was done during the patient’s stay on that unit:
      • arterial catheter placement
      • PEG
      • hemodialysis
      • peritoneal dialysis
      • plasmapheresis
      • non-invasive mechanical ventilation -- includes CPAP, BiPAP, and classic NIV (where a mask is connected to a regular ventilator)
      • debridement
      • tracheostomy placement (i.e. done bedside)
  • We still need to clarify isolation. Currently we are recording 3 different levels of isolation, and none of these relate to use of a negative pressure room. Allan will talk to Bojan to clarify the needs here.

8. Update on seeking data on PHIN validation data, hospitalization data, and mortality data from WRHA.

  • Allan is working on the new PIA.

9. Regarding Sepsis coding. Allan reported that our coding will follow the new Sepsis-3 definitions.

  • This greatly simplifies identification of Septic shock, eliminates SIRS from all sepsis-related definitions, and eliminates what was previously called “sepsis” i.e. SIRS without acute organ failure.
  • For what was previously called “severe sepsis”, the new guidelines merely call “sepsis”, which is identified as acute organ failure caused by proven or presumed infection. The official guidelines operationalize new organ failure as an increase in SOFA score by 2 or more points. Since SOFA scoring is nontrivial, there was concern about whether it is practical for the data collectors to try and do this. It was decided that Laura and some other ICU coders will look at the SOFA scoring grid and we’ll discuss this more next time. -- Tabled today since Laura is not at this meeting.

10. Starting with CLI criteria, there was extensive discussion about the difficulties in adhering to criteria-based diagnoses. *Laura clarified that even more than CLI, VAP requires much checking back and forth at data over time. It was decided that we would like to create wiki-based tools that will make it easier for collectors to do these tasks. The tools would incorporate the diagnosis guidelines into some sort of checklist “machinery”. Trish will assign Laura and a few other coders to work on this.

Next Task Group Meeting: January 4, 2018 at 10:00 am



Database Task Group Meeting December 8, 2017

  • Present: Allan Garland, Con Marks, Julie Mojica, Laura Kolesar, Tina Tenbergen
  • Absent: none Minutes prepared by: AG Action items in BOLD

1. Regarding the influenza coding:

  • We discussed the possibility of going forward with 2 categories of influenza: (1) lab-confirmed and (2) suspected.
    • For lab-confirmed: we will use only the FINAL CADHAM result for this. Thus, we will have to wait for it to be finalized before we can finalize influenza coding. Specifically, we will NOT use the hospital lab rapid influenza test results, or the preliminary Cadham result. Cadham results are on eChart, but not on the regular EMR lab computer. Allan will communicate with the WRHA privacy office to try and get all the collectors eChart access.
    • For suspected: here the clinical team wrote believed that it was influenza, gave a “full course” of anti-influenza drug PLUS either: (a) no swab was sent at all, or (b) swab was sent and FINAL CADHAM result negative. Before we finalize this concept, Allan will talk to infection control.
      • Regarding a “full course of tamiflu”: The usual course of oseltamivir is 5 days. But WHO and CDC recommend that in severe cases the drug should be continued until the infection is resolved or there is satisfactory clinical improvement.
  • We will talk about this more later, and finish the wiki article called “Influenza in ICD10”.

2. Agreed that our new goal for implementing ICD10 and CCI is April 1, 2018.

3. Agreed that high-flow oxygen will NOT be considered to be CPAP or any form of non-invasive ventilation.


ITEMS FROM PRIOR MEETING THAT WE DIDN’T GET TO YET


4. Regarding Palliative care/palliative service. There is an ICD10 code for Palliative care. Allan will update the Wiki on this code, to clarify that by this code we mean a person is getting active palliative care, which may or may not concide with being ACP-C, or having a consult from the Palliative care service.

5. Regarding the list of “reasons for CRRT” that is completed by the Nephro team.

  • After discussion, we agreed that whatever they code should find it’s way into our general list of diagnoses.
  • Towards this end, we agreed that that/those code(s) should be duplicated: (a) in the Temp file for the special purpose of identifying why they were on CRRT, and (b) in our general list of diagnoses. To operationalize this, Allan will identify the ICD10 code(s) that correspond to those diagnoses used by Nephro for this purpose.

6. Regarding Sepsis coding. Allan reported that our coding will follow the new Sepsis-3 definitions.

  • This greatly simplifies identification of Septic shock, eliminates SIRS from all sepsis-related definitions, and eliminates what was previously called “sepsis” i.e. SIRS without acute organ failure.
  • For what was previously called “severe sepsis”, the new guidelines merely call “sepsis”, which is identified as acute organ failure caused by proven or presumed infection. The official guidelines operationalize new organ failure as an increase in SOFA score by 2 or more points. Since SOFA scoring is nontrivial, there was concern about whether it is practical for the data collectors to try and do this. It was decided that Laura and some other ICU coders will look at the SOFA scoring grid and we’ll discuss this more next time.

7. Switching over to ICD-10

  • A number of coders, Tina and Allan are working on Wiki articles for the new ICD10 coding schema.
  • Allan is continuing work on making a set of “quick codes” for both ICD-10 and CCI, that can be chosen as unique entities, to represent procedures that are common, or difficult to otherwise figure out how to code.
  • Regarding the list of acquired complications that previously were singled out to ensure that they were coded: Trish spoke with collectors who indicated that this list is of “high profile” entities that they don’t really think they need reminding about. So, we will bring this information back to the Steering Committee, with a recommendation that there is no need to continue using this list.

8. Regarding switching over to CCI

  • 'Allan is continuing work on CCI coding.
  • There was discussion about whether procedure coding should comprise: (a) fully flexible coding whereby every procedure is constructed by data collectors as a combination of: body part + what was done to it + how it was done, (b) ready-make CCI codes that have been pre-constructed from the native components, or (c) a combination of ready-made codes for the most common procedures, augmented by component construction of codes for the less common procedures. Towards making this decision Allan will send Tina lists of the components to peruse and start sharing with data collectors.

9. Update on seeking data on PHIN validation data, hospitalization data, and mortality data from WRHA.

  • Allan is working on the new PIA.

10. Regarding CLI and VAP criteria: Laura has reworked the articles. Allan will take a look at them.

Next Task Group Meeting: December 20, 2017 at 11:00 am

List of items to bring to task meeting

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