Totals - Requirements & Counting
 
Topics
  1. Down arrow Requirements
  2. Down arrow Columns of rules table
  3. Down arrow Rules table
  4. Down arrow Rules Diagram
  5. Down arrow Sample Report #1
  6. Down arrow Sample Report #2
  7. Down arrow Related Topics

Requirements
Before data is submitted to the QIO's, a topic must meet a minimum number of records to be completed.  The requirement for each topic is:

The total number of completed patients ("All Completed" report) in a topic must be equal to the total number of ranked patients ("All Ranked Patients" report) in that topic.

OR

The total number of patients available for analysis ("For Analysis" report) in a topic must be at least 218.  A patient record is available for analysis if all of the following conditions are met:
  • the patient's condition is confirmed (for example, DM Confirmed = "Yes")
  • the topic is completed - all required elements were provided and all values are valid
  • the record is consecutively completed - there are no incomplete records in between

The first requirement means that 100% of the patients ranked under a topic must have a status of "completed" under that topic.  This applies mostly to topics where there are 218 patients or less.  For example, if there are 100 DM patients, then all DM patients must be completed.

The second requirement applies only to topics with more than 218 patients.  For example, if the number of ranked patients under PC-1 (Blood Pressure Management) is 300, then there must be at least 218 patients with confirmed chronic condition (PC Confirmed = "Yes") with completed PC-1 topic.  These records must also be consecutively completed.  That is, there must be no record with incomplete PC-1 topic between the record with PC-1 rank of 1 to 218 or to whatever is the last record that will met the minimum number of records.  When counting records available for analysis, the tool sequentially looks at all patient records starting from rank 1 to the last.  If a record with an incomplete topic is found, the tool will no longer count that record and records beyond that.  See the diagram and examples below for more information.

It is possible for a topic with 218 or more patients not to meet the second requirement if there are less than 218 patients with confirmed diagnoses.  In this case, the first requirement must be met.  For example, there are 219 DM patients and all of them have been completed but only 217 have a confirmed DM diagnosis.   In this case, only the first requirement is met even though there are more than 218 ranked patients in the DM topic.

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Columns of Rules Table
The table below lists and describes the columns in the Rules Table.

Column Name Description
Report Name Name of the topic report.
Completeness Status The required topic status of the patient (complete, incomplete or any).
Condition Confirmation Indicates the value of the Confirmed element that are counted in the report.
Consecutive? Indicates whether the completed records must be consecutive and there are no incomplete records in between.
Stop If Indicates the condition that will stop the counting of records to be included in the report.

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Rules Table
Below are the rules in counting the total records.  For DM, HF and CAD, the report counts the total per set of patients or denominator and not per measure.  For example, under the DM topic, there are 8 measures but there is only one set of patients, therefore, it gets one total.  In the case of PC topic, each measure under it has different sets of patients so each gets its own total.

Not shown in the table is a rule that applies to all topics which states: for a record to be included in a report it must be ranked in that topic.  For example, if a patient is not ranked in DM (the rank number appears as "-----"), then that patient is not included in any of the DM reports.

Report Name Completeness Status Condition Confirmation Consecutive? Stop If
DM
All Ranked Patients
 DM Topic = Any (Incomplete/Completed) DM Confirmed = Any Value (Yes/No/Med. Rec. Not Found/Blank/(Med. Reasons for DM only) No
All Completed
 DM Topic = Completed DM Confirmed = Yes/No/Med. Rec. Not Found/(Med. Reasons for DM topic only) No
All Incomplete
 DM Topic = Incomplete DM Confirmed = Yes/Blank No
Consecutively Completed
 DM Topic = Completed DM Confirmed = Yes/No/Med. Rec. Not Found Yes DM Topic = Incomplete
Med. Rec. Not Found
 DM Topic = Completed DM Confirmed = Med. Rec. Not Found Yes DM Topic = Incomplete
Not Confirmed
 DM Topic = Completed DM Confirmed = No Yes DM Topic = Incomplete
For Analysis
 DM Topic = Completed DM Confirmed = Yes Yes DM Topic = Incomplete
HF
Same as DM just replace the DM topic with HF in the conditions above.  In the Condition Confirmation column there is not a "Med. Reasons" option under the "HF Confirmed" element.
CAD
Same as DM just replace the DM topic with CAD in the conditions above.  In the Condition Confirmation column there is not a "Med. Reasons" option under the "CAD Confirmed" element.
Report Name Completeness Status Condition Confirmation Consecutive? Stop If
PC-1
All Ranked Patients
 PC Topic = Incomplete/Completed PC Confirmed = Any Value (Yes/No/Med. Rec. Not Found/Blank) No
All Completed
 PC Topic = Incomplete/Completed &
PC1 = Completed (even if there are no visits or all visits are invalid) 		PC Confirmed = Yes/No/Med. Rec. Not Found No
All Incomplete
 PC Topic = Incomplete/Completed &
PC1 = Incomplete 		PC Confirmed = Yes/Blank No
Consecutively Completed
 PC Topic = Incomplete/Completed &
PC1 = Completed		 PC Confirmed = Yes/No/Med. Rec. Not Found Yes (PC Topic = Confirmed & PC1 = Incomplete)
or
(PC Topic = Blank)
Med. Rec. Not Found
 PC Topic = Incomplete/Completed &
PC1 = Completed		 PC Confirmed = Med. Rec. Not Found Yes (PC Topic = Confirmed & PC1 = Incomplete)
or
(PC Topic = Blank)
Not Confirmed
 PC Topic = Incomplete/Completed &
PC1 = Completed		 PC Confirmed = No Yes (PC Topic = Confirmed & PC1 = Incomplete)
or
(PC Topic = Blank)
For Analysis
 PC Topic = Incomplete/Completed &
PC1 = Completed 		PC Confirmed = Yes Yes (PC Topic = Confirmed & PC1 = Incomplete)
or
(PC Topic = Blank)
PC-5
All Ranked Patients
 PC Topic = Incomplete/Completed PC Confirmed = Any Value (Yes/No/Med. Rec. Not Found/Blank) No
All Completed
 PC Topic = Incomplete/Completed &
PC5 Measure = Completed 		PC Confirmed = Yes/No/Med. Rec. Not Found No
All Incomplete
 PC Topic = Incomplete/Completed &
PC5 Measure = Incomplete 		PC Confirmed = Yes/Blank No
Consecutively Completed
 PC Topic = Incomplete/Completed &
PC5 Measure = Completed		 PC Confirmed = Yes/No/Med. Rec. Not Found Yes (PC Topic  Confirmed & PC5 = Incomplete)
or
(PC Topic = Blank)
Med. Rec. Not Found
 PC Topic = Incomplete/Completed &
PC5 Measure = Completed		 PC Confirmed = Med. Rec. Not Found Yes (PC Topic Confirmed & PC5 = Incomplete)
or
(PC Topic = Blank)
Not Confirmed
 PC Topic = Incomplete/Completed &
PC5 Measure = Completed		 PC Confirmed = No Yes (PC Topic  Confirmed & PC5 = Incomplete)
or
(PC Topic = Blank)
For Analysis
 PC Topic = Incomplete/Completed &
PC5 Measure = Completed 		PC Confirmed = Yes Yes (PC Topic  Confirmed & PC5 = Incomplete)
or
(PC Topic = Blank)
PC-6
Same as PC-5-just replace the PC-5 topic with PC-6 in the conditions above.
PC-7
Same as PC-5 just replace the PC-5 topic with PC-7 in the conditions above.
PC-8
Same as PC-5 just replace the PC-5 topic with PC-8 in the conditions above.

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Rules Diagram
Below is a graphical representation of the above rules.
Graphical representation of how the totals are calculated

Reports and the conditions required

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Sample Report #1
This example shows a scenario where there are less than 218 patients under a topic.  In this example, there are 85 patients ranked under the DM topic.  One record is incomplete and one completed record does not have a confirmed DM condition.

Sample DM records
DM Rank DM Status DM Confirmed
1 Completed Yes
2 Completed Yes
3 Completed Yes
4...80 Completed Yes
81 Completed No
82 Completed Yes
83 Incomplete Yes
84 Completed Yes
85 Completed Yes

Sample Totals report
DM : All Ranked Patients 85
All Completed
 84
All Incomplete
 1
For Analysis
 81 (DM rank 1 to 80 and 82)

In the above example, the minimum number of records required is not met since the total number of completed records is not equal to the total number of all patients ranked under the DM topic.  If the patient with DM rank of 83 is completed, the minimum requirement for this topic will be met because 100% of the patients would be completed.

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Sample Report #2
This example assumes there are 327 patients under the PC-1 topic.  There is one incomplete record and one completed record with an unconfirmed condition.  Note: 327 is the maximum number of patients that can be assigned under a topic.

Sample PC-1 records
PC-1 Rank PC-1 Status PC Confirmed
1 Completed Yes
2 Completed No
3 Completed Yes
4...216 Completed Yes
217 Completed Yes
218 Incomplete Yes
219 Completed Yes
220 Completed Yes
221...327 Incomplete Yes/Blank

Sample Totals report
PC-1 : All Ranked Patients 327
All Completed
 219
All Incomplete
 108
For Analysis
 216 (PC-1 rank 1 and 3 to 217)

In the above example the minimum requirement was not met because the total number of DM patients that will be included in the analysis is 216.  The total will increase to 219 if the patient with DM rank of 218 is completed and his/her DM Confirmed is kept at "Yes".  The value of "No" under the DM Confirmed column for patient with DM rank of 2, excluded that record in the analysis.  The incomplete record of the patient with DM rank of 218 breaks the consecutive completed records from 1 to 217.  As a result, records with DM rank of 218 and above will not be counted even if their DM condition& has been confirmed.  The records ranked 221 to 327 are incomplete so they will not be considered in the analysis, even if their DM condition has been confirmed.  If the patient with DM rank of 218 is completed the minimum requirement for this topic will be met.

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Related Topics
Data Status
Totals Report