Victorian Emergency Minimum Dataset (VEMD) User Manual 19th edition 2014–15
Transcription
Victorian Emergency Minimum Dataset (VEMD) User Manual 19th edition 2014–15
Victorian Emergency Minimum Dataset (VEMD) User Manual 19th edition 2014–15 Section 5 Compilation and Submission Download from the Department of Health web site at: http://www.health.vic.gov.au/hdss/ Published By: Authorised By: Version: Year: The Department of Health, Victoria The Victorian Government 50 Lonsdale Street, Melbourne 1.0 2014–15 Contents SECTION 5 Compilation and Submission 1 Compilation Overview 1 Submission Overview 1 File Naming Convention 2 File Structure 3 File Format 7 File Security 7 Transmission of Emergency Department data 8 Penalties for non-compliance 8 Exemptions from penalties 8 Manual aggregate data submission 9 Data resubmissions for previous months 9 Documented Process Requirements 10 Period of Extract 10 Data Quality 11 Input Edits 11 Output Edits 12 Notifiable Edits and Spreadsheet 12 Deletion of Episode Records 12 Test Transmissions 12 VEMD Editor 13 Policy on Data Manipulation 14 Responsibilities of the hospital 14 Responsibilities of DCU 14 SECTION 5 Compilation and Submission This section explains how to compile and submit Emergency Department data to the Department of Health. Compilation Overview The required VEMD format for the financial year applies to presentations with a Departure Date on or after 1 July of that financial year. This includes patients who remain in the Emergency Department after th midnight on the 30 June. st th A financial year starts on the 1 July and ends at midnight on the 30 June. Data for patients who present at the Emergency Department on 30 June 2014 and depart from the Emergency Department on or after 1 July 2014 must be reported in the 2014–15 format and follow the appropriate file naming convention. Note: Data for patients who present and depart from the Emergency Department before 30 June 2014, must be reported in the 2013-14 format. VEMD time data is reported with a precision of minutes rounded down to the lowest minute: For example: 4 hours 8 minutes 17 seconds is to be reported as 4 hours 8 minutes (0408) 4 hours 8 minutes 58 seconds is to be reported as 4 hours 8 minutes (0408) As some data entry systems capture seconds, following this approach will avoid any ambiguity and ensure consistency between different sites. Submission Overview Every electronic file submitted to the VEMD must be: • In the correct file structure • Named according to the file naming convention • Submitted in accordance with the schedule requirements • Sent to the VEMD email address: submit.vemd@health.vic.gov.au • Resubmitted until there are zero REJECTION and NOTIFIABLE errors. VEMD Manual: 19th edition – Section 5: Compilation and Submission Page 1 File Naming Convention Every file submitted to the VEMD must be named as follows: File Naming Convention AAAABnna.txt Where AAAA = Campus Code Example 1111 B = Version of the dataset (last digit) (2014–15 is version 19. Code ’9’ will be used) nn = Month of Transmission (example 07=July) a = Data Submission Indicator Example st 1 July submission 07a nd 2 July submission 07b rd 3 July submission 07c Must be consecutive, with no gaps, commencing with ‘a’ for the first submission for the month. Extract: 1111907a.txt Zip file with 128 bit AES encryption and password supplied by DH: 1111907a.zip VEMD Manual: 19th edition – Section 5: Compilation and Submission Page 2 File Structure The file structure details the sequence, length, type and layout of data items to be transmitted to the VEMD. File Structure Notes: • All fields are data type text • All alpha characters must be in UPPERCASE (optional for Description of Injury Event) • Do not zero fill items unless specified. Padding fields with space characters (either to the left or right) is unnecessary. Mandatory items See the Mandatory Items Key (Table 2) for the conditions under which they become mandatory. Table 1- Data Item Format Key Data Item Max Layout/Code Set Characters 1 Campus Code 4 XXXX 1 Unique Key 9 XXXXXXXXX 1 Patient Identifier 10 XXXXXXXXXX 2 Medicare Number 11 NNNNNNNNNNN or blank 1 Medicare Suffix 3 XXX 14 DVA Number 9 See Section 3 1 Sex 1 1, 2, 3, 4 1 Date of Birth 8 DDMMYYYY 1 Date of Birth Accuracy Code 3 XXX 1 Country of Birth 4 XXXX 1 Indigenous Status 1 1, 2, 3, 4, 8, 9 1 Interpreter Required 1 1, 2, 9 1 Preferred Language 4 XXXX 1 Locality 22 XXXXXXXXXXXXXXXXXXXXXX 1 Postcode 4 NNNN 1 Type of usual Accommodation 2 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 18, 19 1 Arrival Transport Mode 2 1, 2, 3, 6, 8, 9, 10, 11, 99 1 Referred By 2 0, 1, 2, 4, 6, 8, 14,15,16,17,18 19,20 3 Transfer Source 4 XXXX or blank 1 Type of Visit 2 1, 2, 8, 9, 10 VEMD Manual: 19th edition – Section 5: Compilation and Submission Page 3 Key Data Item Max Layout/Code Set Characters 1 Compensable Status 1 1, 2, 3, 4, 5, 6, 7 4 Ambulance Case Number 5 See Section 3 1 Arrival Date 8 DDMMYYYY 1 Arrival Time 4 HHMM 1 Triage Date 8 DDMMYYYY 1 Triage Time 4 HHMM 1 Triage Category 1 1, 2, 3, 4, 5, 6 8 Nurse Initiation of Patient Management Date 8 DDMMYYYY or Blank 8 Nurse Initiation of Patient 4 HHMM or Blank Management Time 9 First Seen by Doctor Date 8 DDMMYYYY or Blank 9 First Seen by Doctor Time 4 HHMM or Blank 8 First Seen by Mental Health Practitioner Date 8 DDMMYYYY or Blank 8 First Seen by Mental Health Practitioner Time 4 HHMM or Blank 13 Procedure 89 XX (x30) Refer Sec 3 12 Clinical Decision to admit date 8 DDMMYYYY or Blank 12 Clinical Decision to admit time 4 HHMM or Blank 1 Departure Date 8 DDMMYYYY 1 Departure Time 4 HHMM 1 Departure Status 2 1, 3, 5, 7, 8, 10, 11, 12, 14, 15, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30 5 Transfer Destination 4 XXXX or blank 1 Referred to on Departure 2 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 16, 17, 18, 19 5 Reason for Transfer 1 1, 2, 3, 4, 5, 6, 7, 9 or blank 6 Departure Transport Mode 2 1, 2, 3, 4, 6, 7, 8, 10, 11, 19 VEMD Manual: 19th edition – Section 5: Compilation and Submission Page 4 Key Data Item Max Layout/Code Set Characters 15 Primary Diagnosis 5 VEMD ICD-10-AM Code 11 Additional Diagnosis 1 5 VEMD ICD-10-AM Code Additional Diagnosis 2 5 VEMD ICD-10-AM Code Nature of Main Injury 2 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 7 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26 7 Body Region 2 F1, F2, F3, F4, F5, F6, F7 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 7 Description of Injury Event 250 Free text 7 Injury Cause 2 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 7 Human Intent 2 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 7 Place Where Injury Occurred 1 H, I, S, A, R, T, C, Q, F, M, P, O, U 7 Activity When Injured 1 S, L, W, E, C, N, V, O, U 16 Ambulance at Destination Date 8 DDMMYYYY 16 Ambulance at Destination Time 4 HHMM 16 Ambulance Handover Complete Date 8 DDMMYYYY 16 Ambulance Handover Complete 4 HHMM Time VEMD Manual: 19th edition – Section 5: Compilation and Submission Page 5 Mandatory Items Key (Table 2) Key Descriptor 1 Mandatory item 2 Mandatory if Medicare Suffix does not equal C-U, N-E or P-N 3 Mandatory if Referred By = 6 4 Should be reported if Arrival Transport Mode = 1, 2, 3, 10 5 Mandatory if patient is transferred to another hospital campus. Departure status is: 17 - Mental Health bed at another Hospital campus 19 - Another hospital campus (excludes for Mental Health and ICU or CCU transfer) 20 - Another Hospital Campus - Intensive Care Unit 21 - Another Hospital Campus - Coronary Care Unit 6 Mandatory where Departure Status code is not 10 – Left after clinical advice regarding treatment options, 11 – Left at own risk, without treatment, or 30 - Left after clinical advice regarding treatment options GP Co-Located Clinic. Blank for Departure Status codes 10 11 or 30 7 See Section 4 – Business Rules, Injury Surveillance. 8 Blank if Departure Status = 8, 10, 11, or 30 9 Blank where Departure Status = 10 – Left after clinical advice, regarding treatment options, 11- Left at own risk, without treatment, or 30- Left after clinical advice regarding treatment options - GP Co-Located Clinic. 11 Mandatory if Primary Diagnosis code = ‘Z099 – Attendance for Follow-up (includes injections) / Review following earlier treatment’. 12 Mandatory if a clinical decision to admit was made, regardless of whether the patient is actually admitted. 13 Optional if Primary Diagnosis item is completed. 14 Mandatory if Compensable Status = 2 15 Optional for Departure Status 10 - Left after clinical advice, regarding treatment options or 30 - Left after clinical advice regarding treatment options - GP Co-Located Clinic. Must be blank for Departure Status 11 – Left at own risk, without treatment, Mandatory for all Departure Statuses other than 10, 11 or 30 16 Mandatory if Arrival Transport Mode = 1, 2 or 3 VEMD Manual: 19th edition – Section 5: Compilation and Submission Page 6 File Format Every file must be submitted: • In the order specified in this document, for patients who depart on and from 1 July 2014 to 30 June 2015(See File Structure). • In tab (not comma) delimited ASCII format. Where data in non-mandatory items is unavailable the field position should be denoted by a tab. • File must contain only valid ASCII characters, with each record separated by a carriage return and line feed • All data elements are data type text • Saved as a text file (.txt) • Compressed into a ‘.zip’ file using a utility such as WinZip, using allocated passwords • Software suppliers are advised to have the capacity to generate earlier versions of the VEMD file formats to enable hospitals to, at any time, extract files using the version appropriate for the extraction period. Also note that in relation to data format: • Data transmitted to VEMD must only include codes specified in the File Structure. Local systems may collect data through the use of other codes, acronyms or text; however, these must be converted into appropriate VEMD format for submission to VEMD. • Only VEMD ICD-10-AM diagnosis codes from the VEMD Library File. The VEMD Library File can be downloaded from: http://www.health.vic.gov.au/hdss/reffiles/index.htm Do not utilise the ICD-10-AM coding books as not all codes are included and a degree of variation exists between codes used in the VEMD and those used in the VAED. • Procedures: Multiple procedure codes will count as one item even though the Manual allows for the transmission of up to 30 Procedure codes. Each Procedure code should be separated by a left curly bracket {. • Description of Injury Event: The text for this item does not need to be enclosed in quotation marks (i.e. “textual information”) as each tab separates the items. Quotation marks can be used to emphasise words within the text. File Security Data files transmitted by VEMD reporting hospitals via electronic mail should be password encrypted using WinZip 128 bit encryption to deter unauthorised access. Passwords, allocated by the department, are required to open VEMD data file attachments. If you have not received a password, please contact the Help Desk at: (03) 9096 8595, see Section 1 for further contact details. VEMD Manual: 19th edition – Section 5: Compilation and Submission Page 7 Transmission of Emergency Department data Emergency Departments will transmit data to the VEMD according to the following timelines: VEMD 2014–15 Timeline All presentation for the first 14 days of the month. At least one submission must be received by the 3rd working day after the 14th of the reporting month (for example, 1-14 July data by July 17). All presentations for the full month. Remainder of the month must be supplied by the 3rd working day of the following month (for example, 15-31 July data by 5 August). All presentations for the full month without errors Must be complete and correct, i.e. zero rejections and notifiable edits by the 10th day of the following month, or the preceding working day if th the 10 is a weekend or public holiday. Any corrections must be transmitted before consolidation of the VEMD database on 31 July VEMD, 201101112 Timeline Health services may submit more frequently than the minimum requirements. The department will endeavour to process submissions within one working day of receipt. Penalties for non-compliance Where health services are non-compliant with these timelines, the department may apply a penalty of up to: • $3,000 if a file containing presentations for the full month is not submitted by the timeline specified above; and/or • $6,000 if a file containing all presentations for the full month, is not without errors by the timeline specified above For further information please go to the Victorian health policy and funding guidelines at www.health.gov.au/pfg Exemptions from penalties If difficulties are anticipated in meeting the monthly timelines, the health service must contact the department, indicating the nature of the difficulties, remedial action being taken, and the expected transmission schedule. A proforma to assist this process is provided on the HDSS website together with contact details for submission (www.health.vic.gov.au/hdss/). Health services are encouraged to flag any emerging difficulties at the earliest opportunity, to enable the department to gauge whether or how best it can assist to resolve these difficulties. Health services are also encouraged to use the forum provided by the VEMD Reference Group to raise issues which may also be of interest or concern to other health services and share knowledge and experience in resolving them. Exemptions for late data penalties will only be considered for circumstances beyond the control of the hospital or health service. Software problems are, of themselves, insufficient justification for late submission of data. Health services are expected to have arrangements in place with their software vendor to ensure that statutory reporting requirements are met. VEMD Manual: 19th edition – Section 5: Compilation and Submission Page 8 Requests for exemption from late penalties will only be considered if received prior to the relevant deadline as outlined above Extensions or exemptions are not issued in advance. Late submissions penalties are assessed after the end of year consolidation deadline taking into account the health service’s submission performance for the financial year. For further information please go to the Victorian health policy and funding guidelines at www.health.gov.au/pfg Manual aggregate data submission For any period that the hospital is unable to supply unit record data, the hospital is required to submit aggregate data using the spreadsheet available from the HDSS website at: www.health.vic.gov.au/hdss Additional penalties may apply for failure to submit aggregate data when required. For further information please go to the Victorian health policy and funding guidelines at www.health.gov.au/pfg Data resubmissions for previous months Health services wishing to resubmit data for a previous period must complete a VEMD Data Resubmission Request (proforma available on the HDSS website www.health.vic.gov.au) as soon as the service is aware of the circumstances requiring resubmission. The request form must be submitted either prior to the resubmission(s) or accompanying the resubmitted file(s). Resubmissions received without the request form will not be processed. VEMD Manual: 19th edition – Section 5: Compilation and Submission Page 9 Documented Process Requirements It is expected that sites will have a robust succession policy to ensure that more than one staff member is aware of processes relating to submission and management of VEMD data at any point in time. To ensure that management of VEMD data is not compromised by staff turnover or modifications to software all procedures relating to the extraction, correction, completeness and accuracy of VEMD data must be clearly documented and accessible. Any manual intervention must be included in documentation to ensure that a whole of process document is available at all times. Leave and staff turnover issues will not automatically be viewed as sufficient grounds for waiving penalties for late submission. Period of Extract All records for patients who depart in a particular calendar month should be submitted in the corresponding monthly file. That is, if a patient attends the ED on 30 July and departs on 1 August, the record should be submitted in the August file (containing departures from 1 August to 31 August), NOT in the July file. VEMD Manual: 19th edition – Section 5: Compilation and Submission Page 10 Data Quality Edits Input Edits Upon receipt, the Department of Health applies a series of ‘input edits’ (see Section 6 - Editing) to the data. These edits are intended to validate certain aspects of the data at the episode level. Wherever possible, edits should also be maintained within the Emergency Department’s in-house data information system to minimise rejection of records from the DH editing program. Section 6 – Edit Reports and Editing provides edits in number order with details of the edit title, data items involved, the effect of the edit, the problem and the remedy. The table below outlines the problem and remedy for the four possible edit effects: Effect Problem Remedy Run terminated The monthly data file is corrupt or contains data that may compromise the dataset Hospital determines and resolves the data problem and resubmits data file. integrity. Rejection Data item/s in the record did not meet the Hospital determines the cause of the criteria specified in the business rules. rejection, corrects it and resubmits the monthly data file. Zero rejections must be achieved for each monthly data file. Notifiable Data item/s in the record could be correct, Hospital determines the cause of the but in reality only on extremely rare occasions. notifiable edit and either : The immediate effect is identical to a rejection. email to DH (see below), with an accompanying data file for the period, Sends a notifiable spreadsheet via verifying the accuracy of the data; OR Corrects and re-submits the record. DH will assess the verification provided and will determine if the record can be accepted into the VEMD or requires further attention. Zero notifiables must be achieved for each monthly data file. Warning Record was accepted but data item/s in the record were questionable. Hospital checks that the data is valid. If necessary, the data is corrected and resubmitted. VEMD Manual: 19th edition – Section 5: Compilation and Submission Page 11 Output Edits As well as editing the data at the episode level, DHalso routinely checks data at an aggregate level. It is possible for data to be valid at the episode level, but meaningless when viewed from a different perspective. For example reporting a Country of Birth of 6106 (Nepal) is valid at the episode level, but if Country of Birth for every episode for an entire month is 6106 then it would be highly unlikely that the data would be accurate. Resolution of these issues usually involves some dialogue between site and DH. It can occur several ways including: • Resubmission, • Software or reference data alteration • DH simply noting it in metadata where unusual occurrences turn out to be accurate • Changes in collection practices, clarification of aspects of collection. It should be noted that data can be considered to be ‘rejected’ at the output edit level as well as the input edit level. Notifiable Edits and Spreadsheet When a record triggers a Notifiable edit, as reported in the Edit List tab of the Edit Reports, the health service must review the record and correct any erroneous data and resubmit. If the service believes the details of the presentation are correct as submitted, the service must complete a Notifiable Spreadsheet template (available for download from the HDSS website at http://www.health.vic.gov.au/hdss/vemd/index.htm. The explanation or circumstances of the presentation will be reviewed by DH and if acceptable the data will be accepted onto the database. If the explanation is not acceptable DH will liaise with the service and provide further advice. The filename convention below for the Notifiable Edit Spreadsheet is: {campuscode version of the dataset month of transmission data transmission indicator}_Notifiables.xls For example: 1390908b_Notifiables.xls Please ensure that the Notifiable Spreadsheet is zipped and encrypted separately to the VEMD submission file. A Notifiable Spreadsheet must be accompanied by a VEMD submission file for the period in which the notifiable presentation occurred. Deletion of Episode Records Deletion of a record previously submitted to VEMD requires the record to be resubmitted with eleven ‘9’s in the Medicare Number field. Simply submitting a file without the deleted record is not enough because all previously submitted records are active unless overwritten by later records with the same Unique Key. It is essential for software to have the capacity to report deletions that occur in-house as they can be a cause of significant confusion and difficulties in reconciliation. Test Transmissions The Department of Health recognises that software suppliers can experience difficulties making the 1 July revisions to their programs and that distributing untested programs to clients is unsatisfactory. It can also be difficult for hospitals to resolve problems caused by using untested software. The Department will therefore be making a test submission facility available to software suppliers and encourages all suppliers to test new programs before using them to send live data to VEMD. VEMD Manual: 19th edition – Section 5: Compilation and Submission Page 12 After making the necessary programming changes to meet the revised requirements, each software supplier can send a reasonable number of tests, without charge. Each test can be sent to the usual submission email address: Submit.VEMD@health.vic.gov.au Tests must be clearly identified as such in the subject line of the email. The Department will endeavour to process and return tests within 3 working days. Staff at the Department may, if requested, assist in identifying problems. However, there is no approval process for testing 1 July updates. Once the supplier and/or the hospital are satisfied that the new software meets the specifications as defined by the Department, live transmissions can commence. VEMD Editor The Department has developed a VEMD Editor that provides hospitals with the opportunity to run their VEMD data through an editing process before sending it toDH. The Editor is designed to reduce the number of submissions and associated administrative overheads that hospitals incur by identifying errors before submission. The VEMD Editor can be used as a guide to assist health services, but Edit Reports returned from the department need to be carefully checked as there may be differences when files are run in the production environment at the department. The MS Access VEMD Editor will be updated to Version 19 in June 2014. Download the Editor and VEMD Editor Process Notes from the website at: http://www.health.vic.gov.au/hdss/vemd/index.htm MS Access 2000 or higher is required to run this software. The software is free and open source. Users are encouraged to identify deficiencies and suggest improvements. Instructions are available on the website. Note: When downloading, disconnect the VEMD Editor from MS Access. VEMD Manual: 19th edition – Section 5: Compilation and Submission Page 13 Policy on Data Manipulation The Department does not condone manipulation of any data extracts (for example with Microsoft Excel, Notepad or any other data manipulation tool) that causes change in data values prior to processing by the Department. The rationale for this is as follows: It is expected that hospitals have a contractual arrangement with software vendors that obliges vendors to provide software to hospitals that allows them to meet their statutory reporting requirements. Hospitals are strongly advised to factor into contract negotiations the impact of data quality and timeliness penalties that may apply where the vendor fails to deliver a product that meets statutory reporting requirements. In effect the vendor’s software should be capable of producing an extract in the format required by the department. The department acknowledges that any software may have the potential to extract data that can trigger “Rejection” edits from time to time. Software vendors and hospitals should work together to ensure that, where this occurs, data can be and are corrected via the hospital’s relevant operational database, thus eliminating the need for secondary data manipulation. • ‘Correcting’ errors in the extract, but not in the hospital’s operational database can lead to a misrepresentation of the hospital’s true position. • There is an audit requirement that data received by DH is an accurate reflection of the hospital’s medico legal system of record. Responsibilities of the hospital In situations where software does not allow the hospital to meet its reporting obligations, hospitals should report the problem to their software vendor immediately, and also notify DH. The terms of the contract with software vendors should ensure that these problems are addressed as a priority. In these situations the use of third party data manipulation software may be an inevitable short-term consequence. In such cases the hospital must: • notify DH in writing of the specific problem, including the affected fields • specify the plan and timeframe negotiated between the hospital and vendor for the resolution of the situation • receive written permission from DH before proceeding with the proposed data manipulation. DH will maintain a register of such occurrences. Failure to meet the above conditions may result in the application of data quality and timeliness penalties. The written permission advice will include a date by which DH expects the problem to be resolved and data manipulation to cease. If the problem has not been resolved by this date hospitals need to advise DH again of progress. Responsibilities of DH In rare circumstances a hospital may prefer DH to adjust an extract in order to address a specific data quality issue. DH will only consider this where: • it believes that all other avenues have been exhausted, and • the hospital requests the changes in writing, confirming that it has made the changes to its own data (or indicating that this is not possible), and • the changes accurately reflect the hospital’s medico legal system of record. DH will maintain a register of such occurrences. VEMD Manual: 19th edition – Section 5: Compilation and Submission Page 14
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