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6. PERFORMING AN
ELECTRONIC AUDIT
RPMS
and certain other electronic health record systems are capable of extracting
audit data from their clinical database, and can create an audit data file.
This eliminates the need to manually review each record and type the data
into the WebAudit. The sections
that follow give a brief step-by-step synopsis of the process using the audit
capabilities of RPMS’ Diabetes Management System (DMS).
More detailed information is available in the DMS
User’s Manual [from the drop-down list of applications, scroll
down and select
"Diabetes Management System"]
In order to use the DMS module, you need to have
the proper access "keys". Otherwise, the necessary menu items
will not show up on your screen. Contact your local site manager if you
need assistance in acquiring the necessary menu and security keys.
a.
Creating a Data File
Before
beginning to create an audit data file, be sure that the following conditions
are met:
-
Taxonomies
of Medications, Lab Tests, Health Factors, and Education Topics are present,
accurate, and complete.
Pay particular attention to the new lipid lowering agents and revised urine protein
taxonomies).
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The
diabetes register is up-to-date, or you have created a search template of
the active diabetes patients at your facility.
When
the above conditions have been met, you can proceed with creating a data file
(also referred to as a .rec file).
Once created, the .rec file can be uploaded to the WebAudit (covered in
Section 6b).
| 1. |
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Go to the Diabetes Management System
(DMS) menu and select “Diabetes QA
Audit Menu (DA)”.
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| 2. |
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Select the most recent audit format, which is the
20 10 Diabetes Program Audit (DM10).
Select “DM10”
again to proceed. [Note:
if "DM10" is not present on your menu, then the necessary
DMS patch has not yet been installed. Ask your IT site manager
to install this patch: BDM v2.0 patch
3].
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| 3. |
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DMS will then ask you to identify the diabetes register that you are
using, and will ask whether your
community receives SDPI grant funds.
If you answer
YES, it
asks for the SDPI grant number, also
known as an Award Number, which can be found in item 3 in the Notice of Award
for your SDPI funds.
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| 4. |
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The
program next asks for the date of the audit.
The date will be the ENDING date of the audit period.
For the annual audit submitted to IHS Division of Diabetes via the
WebAudit, please use the prior calendar year as the audit period (Jan 1 to
Dec 31, 2009), so the audit date would be 12/31/2009. When doing
interim audits, be sure to keep in mind any data entry lag time. For
example, if the data entry staff are about 14-21 days behind, it would be
best to set your ending date perhaps 4-8 weeks earlier rather than using
"TODAY" (i.e., the day the audit is being set up) as the audit
period.
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| 5. |
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You
next select the type of audit sample.
Choices include individual patients, a template of patients
created elsewhere (from Q-Man, for instance), or members of a register,
such as the IHS DIABETES
register.
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| 6. |
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You are offered the option to audit only patients of a particular
provider, or only from a particular
community, if desired.
Almost
always the answer would be “No”
to both for the audit submitted to IHS Division of Diabetes.
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| 7. |
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Next, you
are given the option of auditing ALL the patients you have selected, or a random
sample of the
patients. Most commonly you would
select ALL patients.
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| 8. |
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Choose an output option.
To create a data file, choose option 2 “Create audit data
file". Other available outputs include individual patient
audit reports, a cumulative audit report, or both individual and
cumulative audit reports.
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| 9. |
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If
you have DEMO patients in your Register, you will be given an
opportunity to INCLUDE the DEMO
patients in your output, EXCLUDE the DEMO patients in your output, or include
ONLY DEMO Patients in your
output.
For the annual audit, you
would EXCLUDE the DEMO patients.
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| 10. |
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You will be asked to provide a name (3-8 characters) for the data file.
For example, you might type:
SAMPLE10.
The program will ask if everything is OK to proceed, and then will create
a data file named
SAMPLE10.rec.
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The newly created file will be placed in the same directory that the data
export files are placed.
You will probably need the site manager or other IT professional to
retrieve the file and forward it to you.
Keep track of where you put
the data
file!
If you have a tendency to be absent minded or forgetful, you might want to make a
new folder called “Audit Files” on your desktop or in My Documents.
Then you will have a specific place to put the new data (.rec) file.
It is this file that you will upload to the WebAudit.
It is also readable in Epi Info, if that is of interest to you.
The next section discusses how to get the file into the WebAudit.
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