Form 0920-0976 Data Verification Form

ATTACHMENT 4

DATA COLLECTION TOOL #2

Million Hearts® Hypertension Control Champion
Data Verification Form

Form Approved

OMB No. 0920-0976

Exp. date 12/31/2019

Million Hearts® Hypertension Control Champion Data Verification Form

Public reporting burden of this collection of information is estimated at 2 hours per response, including the time for reviewing instructions, providing access to records, access to the Electronic Medical record, or access to the EMR vendor. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, NE, MS D-74, Atlanta, GA 30333, ATTN: PRA 0920-0976.

Applicant: _________________________________________________________

Applicant information:

Name: ________________________________________________________________________

Address: _______________________________________________________________________

Phone: ________________________ E-mail: _________________________________________

Review of Application Form:

1. Number of patients enrolled in the practice or health system: _____________________

2. Number of adult patients (ages 18 - 85) seen at least annually: __________________________

3. Are there patient demographics that justify a proportion of the population with hypertension different from the national rate e.g., ages, race/ethnicity, Medicaid eligible, Medicare eligible: __________________________________________________________________-

4. How many adult patients (ages 18-85) in the total patient population seen annually are diagnosed with hypertension (denominator)? ________________

5. How many adult patients (ages 18-85) are excluded from the denominator?

6. How many of these patients had their blood pressure controlled (<140/<90)?

7. What is the Hypertension Control Rate for the practice or healthcare system’s adult hypertensive population? __________________ Date of reporting period ________________.

Questions for nominee:

1. How are blood pressure measures collected?

   1. Are there protocols in place if an abnormal value is measured?

   2. Which blood pressure measure is recorded? The second? An average?
      
      
      

2. If the hypertensive population (or denominator) is defined by methods other than published measures, such as NQF #0018, describe how the population was defined?

   1. Are there exclusions and if so, what are the exclusion criteria?

   2. How are hypertensives identified in the patient records?
      
      
      

3. How often is the hypertensive population updated?

   1. Does the denominator only include hypertensives that have had at least one office visit within the past year? (current patient population)

4. How often are the data validated?

   1. Are records randomly selected to validate the hypertension diagnosis in the records?

   2. Are records reviewed for accuracy in hypertension diagnosis? (Some EHRs might have information only contained in text fields that cannot be easily accessed.)

5. How do prevalence of hypertension and control compare to other available data?

   1. Are there more hypertensives at this clinic compared to others in the community?

   2. Are the control rates much higher than are seen locally or nationally?

The contractor doing the data validation will provide you with complete instructions on the data validation procedures. You will first submit a de-identified list of your patients with hypertension. The validator will randomly select up to 40 patients. You will then be given instructions on how to submit the medical records for the randomly selected patients through a secure data system. Do not submit any patient records by email.