2015-06_ResiCAT_USER-MANUAL_v1.5KB_June_DRAFT-ONLY

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Animated publication

Version 1.5

June 2015

D. Abbott J.Holman C.Warr

1st Release revised

ResiCAT User Manual

This document and the information disclosed herein are confidential and proprietary to Resolutions (Int) Pty Ltd. The other parties' confidential or proprietary information may not be used or disclosed to any third party for any purpose other than that specifically authorised in writing by Resolutions (Int) Pty Ltd.

Developed date: December 2013 Revised date: June 2015 Revised by: Debbie Abbott Due for review: October 2015 Authors: Debbie Abbott and Cath Warr Health Information Consultants Resolutions (Int) Pty Ltd

Approved by: Debbie Abbott Director Resolutions (Int) Pty Ltd

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TABLE OF CONTENTS

TABLE OF CONTENTS 1.1

P URPOSE OF D OCUMENT

1 1 1 2 3 7 8 9

L OGGING O N

1.2 1.3 1.4 1.5 1.6 1.7 1.8

F ORGOT YOUR P ASSWORD C HANGING YOUR PASSWORD

S ELECTING ACCESS TO THE G ROUPER

A DDING A U SER D ELETING A U SER L EAVING A P AGE

HOME PAGE

10 10 11 11 11 11 13 16 19 20 20 22 22 28 28 28 29 29 30 30 31 31 32 32 33 34 34 34 38 40 43 45 49 49 50 51 52

W ELCOME TO R ESI CAT

2.1

DATASET SETUP

A UDITING FOR THE F IRST T IME (C REATE D ATASET )

3.1

3.1.1 3.1.2 3.1.3 3.1.4

File Format Import data

Select criteria for subset

Save the dataset

C HECKING THE S TATUS OF A D ATASET M AKING A D ATASET I NACTIVE H OSPITAL D EFINED F IELDS (HDF)

3.2 3.3 3.4

CODING AUDIT

A UDIT AFTER INITIAL SELECTION OF DATASET (F IND D ATASET ) N AVIGATION T IPS DURING R ECODING AND C ODING C OMPARISON

4.1 4.2 4.3

C HECK E PISODE D ETAILS

4.3.1 Admission Date and Time 4.3.2 Discharge Date and Time

4.3.3 Date of Birth 4.3.4 Gender 4.3.5 Care Type

4.3.6 HITH, MV Hours, ICU Hours, Admission Weight, Leave Days

4.3.7 Mental Health Legal Status 4.3.8 Mode of Separation 4.3.9 Admission Source 4.3.10 Admission Type 4.3.11 Criterion of Admission

C ODE THE E PISODE

4.4

4.4.1 4.4.2

Diagnoses Procedures

C ALCULATE THE DRG C ODING C OMPARISON

4.5 4.6 4.7 4.8

E RROR L OG B OXES E XPLAINED

C OMPLETE E RROR L OGS

4.8.1 4.8.2 4.8.3 4.8.4

Enter Log for code error

Error Type

Reason For Error

Notes

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4.8.5

Error Log not required

53 54 55 56 59 60 62 62 63 66 66 68 69 70 71 71 72 73 74 75 78

4.8.6 Summary of Errors

4.8.7

Enter Log for DRG Change

4.9

C HANGING A UDIT D ETAILS

4.10 M ARK AS C OMPLETE

A DD A C OMMENT

4.11

REPORTS

E PISODE R EPORT

5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9

A UDIT S UMMARY R EPORT

A UDITOR T HROUGHPUT R EPORT

E RRORS R EPORT C ODERS R EPORT

D ATA S ET L ISTING R EPORT A UDIT D ETAIL R EPORT

D RG R EPORT O UTPUT F ILE N WAU E XPORT

5.10 I NCOMPLETE R EPORT 5.11 E PISODES F IELD R EPORT

5.12 WIES R EPORT

TROUBLESHOOTING

6.1 G ROUPER IS NOT WORKING ( ONLY RELEVANT IF USING GROUPER ON PC OR LAPTOP ) 78 6.2 S YSTEM IS HANGING 78 6.3 I MPORT DATA IS NOT IN CORRECT FORMAT 78 6.4 I NDIVIDUAL LINES BETWEEN CODED DATA IN AUDITOR SCREEN 78 6.5 I CAN’T SELECT A CODE FROM THE DROP DOWN BOX 80 6.6 C LEARING THE CACHE 80 7 DEFINITIONS 81 7.1 C LASSIFICATION OF C ODING C HANGES – E RROR T YPE 81 7.2 C LASSIFICATION OF C ODING C HANGES – R EASON FOR E RROR 82

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INTRODUCTION 1.1

P URPOSE OF D OCUMENT The purpose of this document is to provide a guide on how to use and administer ResiCAT, a clinical coding audit tool developed by Resolutions (Int) Pty Ltd. ResiCAT provides a web based application to conduct blind and open recoding audits of coded datasets. 1.2 L OGGING O N Access to ResiCAT is via the following hyperlink https://www.resicat.com.au/resicat NOTE: Preference of web browser is the Internet Explorer if using the local grouper due to 3M grouper requirements. Any other web browser is compatible when using the cloud grouper.

Before you begin you will be given an email username and password.

Enter the username and password that have been allocated to you.

NOTE: The RESET button on this screen enables you to clear the fields so you can enter new data.

F ORGOT YOUR P ASSWORD

1.3

If you have forgotten your password, select the ‘Forgot your Password’ hyperlink indicated in the screen shot below.

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Enter your email address and click on the RESET PASSWORD hyperlink. Your password will be emailed to the email address you entered. You can then click on CLICK HERE TO LOGIN. The standard login screen (shown above) will appear and you can proceed as normal.

NOTE: For security reasons, you will be required to enter a password, 12 to 16 characters long consisting of alphanumeric characters with capitals and at least two symbols. Eg. CharacTers99$$ 1.4 C HANGING YOUR PASSWORD

If you wish to change your password you must log on, click on the organisation name at the top right, then click on CHANGE PASSWORD in the drop-down menu.

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The screen below will appear. Complete the fields then click on RESET PASSWORD.

NOTE: For security reasons, you will be required to enter a password, 12 to 16 characters long consisting of alphanumeric characters with capitals and at least two symbols. E.g. CharacTers99$$

The RESET button on this screen enables you to clear the fields so you can enter new data.

S ELECTING ACCESS TO THE G ROUPER

1.5

There are two options for accessing the DRG Grouper: it can be done locally using a grouper loaded on a PC or laptop, or by using the grouper provided by Resolutions via an internet cloud. It is recommended that you select the cloud grouper as the default option.

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Click on the organisation name in the right-hand corner, then select MY ACCOUNT.

When the EDIT YOUR ACCOUNT screen appears, select either LOCAL or CLOUD, as seen below.

If you select CLOUD, no further action is required. Then click UPDATE. If you select LOCAL in the field labelled 3M Grouper Path, enter or update the pathway to the 3M DRG Grouper on your C: drive. Then click UPDATE. NOTE: This instruction is applicable to those using ResiCAT linked with a grouper on a PC or laptop. In Release 1 this option requires linkage to the 3M DRG Grouper and your default browser must be Internet Explorer.

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NOTE: For ResiCAT to work properly you must also ensure that the website address is included as a Trusted Site. To do this, click on the Internet Tools icon in the top right hand corner of your screen. Select ‘Internet Options’ then ‘Security’ then ‘Trusted Sites’. Copy the ResiCAT website address into the box that is displayed.

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A DDING A U SER

1.6

To add a User click on the ‘USERS’ option in the drop-down menu. Please note, you must have "administrator" rights to perform this function.

A list of existing users will appear. The right-hand column labelled ACTION will be blank next to your own entry but the option to ‘Delete’ will be shown next to other entries in the list. Click on the ADD USER button at the top right side of the page. The following ADD USER screen will appear:

Complete the First Name, Surname and Email fields. Tick whether the new user will have Administrator or User level of access, then click on the CREATE USER button. The screen will return to the previous list of users and the one you have added should now be included.

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The new user will receive an email letting them know they have access to ResiCAT and providing them with a password.

To exit the Users screen, click on DATASET SETUP or CODING AUDIT in the top bar or if you wish to leave the system, click on LOGOUT in the organisation’s drop-down menu.

D ELETING A U SER

1.7

Access the USERS screen as described in 1.6 above. When the list of users appears, click on DELETE in the right-hand Action column for the user you wish to delete. The message ‘Are you sure you want to delete this user?’ will appear.

Click on OK to confirm you wish to delete this user. The screen will refresh and the user you deleted will no longer be listed.

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1.8 L EAVING A P AGE

When you close a screen the message highlighted in the screen shot below will appear:

Click on LEAVE THIS PAGE if you want to close the screen you are on.

NOTE: Data such as codes that you enter are automatically saved as you go along so when you leave a page no ‘Save’ action is required.

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HOME PAGE

2.1 W ELCOME TO R ESI CAT Once you log on to ResiCAT you will be presented with the ResiCAT Home Page which provides icons to access the following sections:

Dataset Setup Coding Audit

   

Reports

HDF Setup

The HDF (Hospital Defined Fields) module enables an organisation to audit fields located originally from its Patient Administration System (PAS) software OR include fields from the PAS that are unique to audit such as accommodation for example. It is also able to capture data specific to your organisation or state but which are not an integral part of the PAS software. NOTE: The HDF module is separate and additional to the core ResiCAT software and will only be active if your organisation’s ResiCAT licence includes the HDF module.

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DATASET SETUP

A UDITING FOR THE F IRST T IME (C REATE D ATASET )

3.1

3.1.1 File Format There are two types of file formats that are acceptable, the first option is a csv file, where there is one row per episode, so all ICD codes are listed on the one line. The alternate file format is an xls file, where there is one ICD code per row. The preference is option one, one line per episode, however you can choose either. Both options require the following parameters:  File must have at least 1 record  UMRN & Admission Number fields cannot be blank, if blank episode will be ignored  Header row must be included, as the first row is always ignored. However header names don’t have to match sample file.  Fields must be kept in this order

An example of option one file format is below.

An example of option two file format is below.

The above examples of the file formats indicate the way in which data needs to be displayed e.g. admission time displayed as 1221 or 12:21:00. There are also exact requirements to operate the grouping software. For example diagnoses must be displayed with dots and dashes. i.e. K21.9 instead of K219 and 95550-03 instead of 9555003

Please note there are different file requirements for each state due to the different criteria collected. For example, criterion for admission is only required for Victorian hospitals.

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3.1.2 Import data The first time you log into the system, you need to select your data source. To begin this process, click on DATASET SETUP.

The screen below will appear.

Click on SELECT FILE. You can then browse to the drive or place where you have stored your selected dataset. Select the dataset and double click. The system will now import the dataset into ResiCAT. NOTE: The dataset cannot be imported unless it is in the required format. Please see appendix 1 for a detailed description regarding acceptable file formats. If the format is incorrect a message will appear to advise the user. If you receive this message please contact the administrator immediately as there may be issues with your dataset structure.

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3.1.3 Select criteria for subset When the data import has taken place the screen below will appear.

Note that the program is defaulted to VIEW ALL episodes in the dataset so all the records in the imported dataset will be listed. From this point you have the option to create a subset to work with and/or select a random sample of a defined size from the whole dataset or the subset. You may choose to select episodes to audit by unticking those you do NOT want. This can be done whether you choose SELECT CRITERIA or not. When you click SAVE only the ticked records will be included in the saved file. If you do not want to select any of the criteria, go directly to the SAVE button. If you wish to choose a subset from the data using certain criteria, tick SELECT CRITERIA. When the screen refreshes a default range of discharge dates will appear, these being from 01/01/1900 to the current date. You can select discharges in a certain date range by entering the dates using the calendar provided beside each date box or by typing over the dates that are there, as indicated by the orange arrows in the screen shot below. NOTE: In the Dataset Setup screen the DRG is visible but once you have created and saved your audit dataset, the DRG will not be displayed in the list for the blind option only. This is to ensure the auditor’s code selection is not influenced by knowing what the original DRG was. The original and audit DRGs will both be displayed in the Coding Comparison screen (see Section 4.6).

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Once you have ticked SELECT CRITERIA, you can specify the discharge dates or choose one of the options in the PARAMETER drop-down box, indicated by the green arrow in the screen shot above. The options are:

All

    

DRG

Diagnosis Procedure Coder ID

Make sure that once you make your selection you then press the "Go" button to include your selections. Exclusions There is now the option to exclude certain episodes from the dataset. Common exclusions include day chemotherapy, day dialysis and newborns which are not always required in coding audits.

The exclusion categories include  DRG  Principal diagnosis  Procedure

You can also select whether you want the dataset to select a random sample or not and what sample size you wish to use.

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If you want a random sample, tick the box FROM THIS DATASET DO YOU WANT TO SELECT RANDOM SAMPLE? When you tick the box the total number of records in the dataset will appear next to ENTER SAMPLE SIZE. Delete that number and enter the sample size you want as shown in the screen shot below. NOTE: You must have changed from VIEW ALL to SELECT CRITERIA for random selection to be operative.

Once you have indicated your criteria, click on GO. The screen will refresh to show the selected list. The screen shot below is an example of a subset that has been selected by DRG.

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3.1.4 Save the dataset The number of records in the data subset created by the criteria you selected is shown under SAVE DATASET, # of records.

When saving a file you must make a selection in the HDF field even if your licence does not include the HDF module. Select NO HDF FIELDS as shown below. If you do have the HDF module, select a configuration for the HDF fields from those you have set up beforehand.

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Choose the DATA VALUE TYPE of your dataset from the drop-down menu which lists common types of formats of audit data e.g. VIC -VAED, NSW – ISC - or as shown in the screen shot below.

The Data Value Type you select here controls the values in the drop-down menus accessed during the coding phase of the audit and the overall format of the stored data.

It is mandatory to select a Data Value Type. If you don’t, the dataset cannot be saved and an error message will appear. If you have already used a dataset previously, this will automatically default to the correct dataset value type. At this point there are several other tick boxes to complete (indicated by the arrows in the screen shot below):  If you want to be able to enter a diagnosis code more than once, tick the first box labelled ALLOW DUPLICATE DIAGNOSES.

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 If you want to be able to audit the Condition Onset Flag, tick the second box labelled AUDIT COF.  If you want to audit via open or blind method, tick the third box labelled OPEN AUDIT, otherwise a blind audit screen will apply to the audit dataset.  If you want to make the log notes in the audit screen compulsory, tick the fourth box labelled MAKE LOG NOTES COMPULSORY. Refer to the screen below.

NOTE: It is suggested that you make the log notes mandatory as the more notes you have about your audited episodes the better for reporting purposes. A hint is that make sure that the auditors using the notes are consistent in their terminology.

In the field labelled HOSPITAL NAME enter the hospital’s name (for some facilities this will be prepopulated) and in the field labelled DATASET NAME, enter a name for the dataset. If you have already used a dataset previously, this will automatically default to the hospital name. The name you enter at this point will be the file name you use to retrieve the dataset at the next stage. As you may create any number of subsets from the full dataset, it is recommended that you name the file in a way that will assist in identifying its contents.

A message will appear to let you know that the dataset has been saved successfully.

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C HECKING THE S TATUS OF A D ATASET

3.2

The status of a dataset can be checked at any time. Click on the CODING AUDIT button then click on SEE ALL DATASETS.

The following screen will appear:

As seen in the screen shot above each dataset shows:  Dataset name  Number of episodes in the dataset  Date the dataset was created 

Data value i.e. the format that will govern the display of data  Whether duplication of diagnosis codes is allowed  The status of the file i.e. Active or Inactive Any of the columns underlined can be reordered simply by clicking on the heading of the column.

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M AKING A D ATASET I NACTIVE

3.3

The default for a dataset is Active. To make a dataset inactive click on ‘Active’ for the relevant dataset and it will change the status to ‘Inactive’.

An Inactive dataset cannot be opened by a person with User level access to ResiCAT but an Administrator can change the status back to ‘Active’ by clicking on ‘Inactive’. It is the intention of this system not to delete datasets in case comparisons of datasets might be required in the future. It is also a 'fail safe' feature of the system to ensure administrators do not 'accidentally' delete a dataset.

H OSPITAL D EFINED F IELDS (HDF)

3.4

If you purchase the licence for the HDF module you will be able to audit specific parameters through ResiCAT at the time of conducting the coding audit. The purpose of the hospital defined fields is to be able to audit other criteria collected in the dataset or to create your own. This includes documentation to compliment your coding audit. An example is "Is there a discharge summary present" where the user can define the value, eg. 1 = yes or 2 = no. The HDF fields are defined by the hospital and require a description, value type and value as seen in the screen shot below. The HDF fields must be set up prior to the commencement of auditing to enable the collection of the data.

The HDF fields are set up to be audited at the time of coding as seen in yellow in the screenshot below:

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CODING AUDIT

A UDIT AFTER INITIAL SELECTION OF DATASET (F IND D ATASET )

4.1

NOTE: The system will automatically log you out after 30 mins if you are not actively using it. This can be adjusted if required. Please contact the administrator.

Once you have selected and saved your dataset you are ready to audit. Click on CODING AUDIT at the top of the screen.

There are two ways of finding the dataset you wish to audit. 1. Type the exact name of the dataset you want into the blank box then click on FIND. 2. If you are unsure of the name of the dataset click on SEE ALL DATASETS.

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When you click on See All Datasets, a list of the datasets to which you have access will be displayed. Select the dataset you want by highlighting it with the arrow key and double click.

Once selected by either method, the episodes in the dataset will be displayed as shown in the screen shot below. Note that the DRG is not displayed in this list if a blind audit is selected. You can reorder any of the columns underlined simply by clicking on the heading. For example, if you wish to list the dataset by admission date, then click on the admission date heading.

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The following screen shot shows what the Coding Audit screen might look like while an audit is in progress:

When the list of records in the dataset first appears all episodes will be listed as ‘Un- audited’ in the Status column and ‘Audit’ will be written in the left-hand column.

If an episode has been opened but not completed, the Status column will show it as ‘Incomplete’ and the left-hand column will still say ‘Audit’ . An Incomplete episode may or may not have codes entered by the auditor, but it has not been grouped. When the episode has been coded and grouped by the auditor but not marked as Complete the episode will display in the list as ‘Grouped’ . The Error Logs may or may not have been completed (see Section 4.6). The left-hand column will display as ‘View’ . When the episode has been fully audited and the ‘Mark as Complete’ button has been clicked (see Section 4.7), the Status column will say ‘Audited’ and the left-hand column will display as ‘View’ . The name of the auditor who last worked on an episode will appear in the ‘Last Auditor’ column for those records shown as ‘Incomplete’ , ‘Grouped’ or ‘Audited’ . A date will only appear in the Date Audited column when the episode has been marked as complete.

NOTE: Statistics relating to the audit are only calculated on records marked as complete. Reports provided by ResiCAT are described in Section 5.

If your licence includes the HDF module the status of auditing of the HDF fields will also be displayed in a similar manner as can be seen in the screen shot above.

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If you wish to print the list of records in the dataset, click on the DATASET LISTING REPORT button (circled in red in the screen shot below).

There are several methods that the dataset listing report can be displayed for printing. You can choose to order it by terminal number, standard numerical or by discharge date as demonstrated in the screen shot below.

To commence (or resume) the audit, select the first episode listed (or any record shown as incomplete in the list) by highlighting it with the arrow key and double clicking. An example of the dataset listing is in the below screen shot.

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You can find a particular record by entering it in the box labelled FIND UMRN (circled in red in the screen shot below). As soon as the system recognises the number it will display this record. Double click on the line to begin auditing this record. NOTE: Clicking on VIEW in the LOGS column enables you to see an audit trail of changes the auditor has made during the audit process. NOTE: When you open an episode displayed as Grouped or Audited, the episode opens on the Coding Comparison screen, that is, it skips the code entry screen displayed in the next screen shot.

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When you have selected an Unaudited or Incomplete episode the following screen will appear. The imported details for the episode will be displayed on the left-hand side in the EPISODE DETAILS box. Note that, for an episode marked as Incomplete, any data previously entered or changed will have been saved and will be displayed.

The steps of the recoding and audit process are then: 1. Check Episode Details and amend any item that is incorrect.

2. Code the Episode , entering the selected codes in the appropriate boxes. You will notice when you start to enter an ICD-10-AM code, it will list all fourth and fifth digit options of the three digit rubric eg. I20 will list as I20.0, I20.1 etc. You can just select the correct code from here. NOTE: This should occur in all internet browsers but known issues have occurred when using Google Chrome. 3. Calculate the DRG. 4. Click on the Coding Comparison button. The system will then display the original set of codes and DRG and those entered by the auditor and any differences will be highlighted. 5. Complete the Error Log for any discrepancy identified including change of DRG. 6. Click on the Mark as Complete button to indicate you do not want to make any changes. 7. Add Comments about the episode if desired. NOTE: You can return to the Coding screen to amend the auditor’s coded data but you will have to recalculate the DRG if you do so. To protect the integrity of the blind recoding audit methodology, an audit trail is maintained of any changes made to the auditor’s codes after the initial data entry.

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N AVIGATION C OMPARISON

T IPS DURING

R ECODING AND

C ODING

4.2

If you need to go back to the previous screen, click on the BACK tab on the bottom left-hand corner of the screen as seen in the screen shot below.

The NEXT button in the bottom right-hand corner will take you to the Coding Comparison screen but you will NOT be able to go to the Coding Comparison screen until codes are entered and the CALCULATE DRG button has been clicked and a DRG generated. This ensures that the results are not compromised and a true blind audit has been conducted. 4.3 C HECK E PISODE D ETAILS

Data fields that a hospital may wish to audit are listed under the EPISODE DETAILS section on the left-hand side of the screen. Some fields may impact on the DRG.

If a data item is not correct, you should change it so that the correct data is displayed. Any item you change will be highlighted in orange. When you move to the Coding Comparison screen a comparison of the episode details will appear and any difference will be highlighted in purple.

4.3.1 Admission Date and Time The first listed data field is ADMISSION DATE / TIME. If the data displayed is incorrect the auditor can type over the admission date that is listed in the auditor column or change the date by clicking on the calendar and selecting the correct date as shown below. NOTE: the original hospital values listed in the hospital column of the coding comparison screen cannot be altered. Only the auditor values can be changed. To change the admission time, simply type over the admission time shown.

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4.3.2 Discharge Date and Time The next listed data field is DISCHARGE DATE / TIME. If the data displayed is incorrect the auditor can type over the discharge date entered or change the date by clicking on the calendar and selecting the correct date as shown below. To change the discharge time, simply type over the discharge time shown.