slide 1

Collection and Use of Race and Ethnicity Data for Discharge Data Reporting Systems: The New Mexico Race/Ethnicity Data Project

State of New Mexico Department of Health logo

Noell Stone, MPH
Nicole Katz, MPH
July 12, 2012

AHRQ R01 HS20033-01

slide 2

Team Members

Epidemiology and Response Division New Mexico Department of Health

Funder: Agency for Healthcare Research and Quality (AHRQ)

• Principal Investigator: Michael Landen, MD MPH
• Data Manager: Terry Reusser, MBA
• Project Director/Epidemiologist: Noell Stone, MPH
• Epidemiologist: Nicole Katz, MPH

slide 3

Purpose

To improve the collection of Race/Ethnicity/Tribal Identification data collected by hospitals

slide 4

New Mexico Population

2,059,179 people resided in New Mexico during 2010

• 41% of the population lives in the metropolitan areas of Albuquerque, Santa Fe, Farmington and Las Cruces
• 22 American Indian Tribes have land within borders of New Mexico

Pie chart. New Mexico Race Demographics from 2010 Census. White 68%; American Indian/Alaskan Native 10%; Black 2%; Asian/Pacific Islander 1%; Other 15%; Multiple race 4%.

Pie chart. New Mexico Ethnicity Demographics from 2010 Census. Hispanic 46%; Non-Hispanic White 54%.

slide 5

Hospital Inpatient Discharge Database (HIDD)

• Pursuant of the Health Information Systems Act (HIS) created by the Health Policy Commission (HPC)
• Goal: Collect, disseminate and analyze health data for public and private use to influence planning and policy development.
• Information including utilization, reasons for hospitalization, surgical procedures, diagnoses, patient demographics including race, ethnicity and tribal affiliation and payer

slide 6

Outline

• What are the guidelines for data collection?
• How can we improve the collection of race/ethnicity/tribal affiliation data?
• What are the common issues found in collecting, analyzing and reporting this data?

slide 7

What are the guidelines for data collection?

slide 8

Gold Standard for Data Collection by OMB 1997 Guidelines

• Self-identification/Self-Report
• Allowing for multiple race/tribe
• Asking for this information orally

slide 9

NMAC - Data reporting requirements for healthcare facilities

• Statutory requirement for state to collect data (NMSA 1978 24-14a Health Information System Act (HIS Act))
• Based on OMB Standards of 1997

Q1: Ethnicity

E1-Hispanic /Latino
E2- Not Hispanic/Latino
E6- Declined*
E7- Unknown*

Q2:Race

R1-American Indian/Alaska Native
R2-Asian
R3-Black or African American
R4-Native Hawaiian/Pacific Islander
R5-White
R7-Unknown*
R9-Other Race*

Q3:Tribal Affiliation

T1-Acoma Pueblo
T2-Cochiti Pueblo
T3-Isleta Pueblo
T4-Jemez Pueblo
T5-Jicarilla Apache Nation
T6-Kewa/Santo Domingo Pueblo
T7-Laguna Pueblo
T8-Mescalero Apache Nation
T9-Nambe Pueblo
T10-Navajo Nation
T11-Ohkay Owingeh Pueblo
T12-Picuris Pueblo
T13-Pojoaque Pueblo
T14-San Felipe Pueblo
T15-San Ildefonso Pueblo
T16-Sandia Pueblo
T17-Santa Ana Pueblo
T18-Santa Clara Pueblo
T19-Taos Pueblo
T20-Tesuque Pueblo
T21-Zia Pueblo
T22-Zuni Pueblo
T100-Other Tribal Affiliation
T200-Declined
T300-Unknown

slide 10

How can we improve the collection of race/ethnicity/tribal affiliation data?

slide 11

Levels of Influence in Hospitals

Graphic Diagram showing the Health Information Systems Change Act as an example of influence on the federal and state legislation level; Regulation Change N M A C 7.1.4 as an example of influence on the policy and administration institution level; and hospital training, focus groups, site visits to hospitals, patient telephone surveys, and key informant interviews as examples of influence on the operational level (that is, at the level of data managers, IT systems, registration personnel, and patients).

slide 12

Path of Patient Data

Flow chart showing the following chronological steps: From Patient to Registration to Electronic Health Record to both I T /Data Manager and Billing, and from I T /Data Manager to D O H.

slide 13

Policy Change

• New Mexico Administrative Code (NMAC 7.1.4) changed as of January 2011
• Submit HIDD quarterly instead of annually
• Race and Ethnicity as separate variables
• Tribal Affiliation collected
• Allow for multiple race and tribe
• As of 2012, HIDD now resides at NMDOH

slide 14

Hospital Training

• Health Insight NM- contracted to educate and train registration staff to better collect race/ethnicity/tribal affiliation data
• Nine pilot hospitals have already received education and training in Summer 2011
• Next round of training occurring now through early Fall 2012
• 8 hospital trainings complete; 35 hospitals still need training
• Goal: Reduce barriers of race/ethnicity/tribal affiliation data collection to increase completeness and quality of this data

slide 15

Training Evaluation

• Key Informant Survey
• Pre and Post Tests
• Day of the training and three months after training

slide 16

How do we evaluate hospitals?

• Feedback to hospitals:
• Hospital Specific Progress Reports describing:
• Patient demographics compared county population
• Status of submitted data
• Possible issues with data collection

slide 17

New Mexico Race and Ethnicity Data Quarter One Report

DATES: January 1, 2011 - March 31, 2011

FACILITY NAME: SAMPLE

FILES RECEIVED: Yes

NUMBER OF RECORDS: 3119

QUARTER 1 RACE AND ETHNICITY VARIABLE EVALUATION:

PERCENT OF:	(%)	NUMBER OF:	(n)
Patients with Ethnicity Coding	100.0	Patients with Ethnicity Coding	3119
Patients with Missing Ethnicity	10.0	Patients with Missing Ethnicity	312
Patients with Unknown Ethnicity	0	Patients with Unknown Ethnicity	0
Invalid Ethnicity Entries	0.0	Invalid Ethnicity Entries	0
PERCENT OF:	(%)	NUMBER OF:	(n)
Patients with Race Coding	100.0	Patients with Race Coding	3119
Patients with Missing Race	0.0	Patients with Missing Race	312
Patients with Unknown Race	0	Patients with Unknown Race	0
Invalid Race Entries	0.0	Invalid Race Entries	0
R1 (Native American) Patients with Tribal Affiliation	INVALID	R1 (Native American) Patients with Tribal Affiliation	INVALID

COMMENTS:

• Patients were categorized as American Indian, however there are no tribal identifiers. Those that are American Indian should have a tribal affiliation. All other races should not have a tribal affiliation.

QUESTIONS:

• Were race/ethnicity/trabal affiliation fields based on self-report?

slide 18

Comparison of Inpatient Hospital Race and Ethnicity Demographics to County Level

Graphic - clockwise from upper left:
Pie chart. American Indian or Alaska Native 30%; Asian 20%; African American/Black 20%; Native Hawaiians or Pacific Islander 5%; White 10%; Other 5%; Two or more races 10%.
Pie chart. American Indian or Alaska Native 2%; Asian 0%; African American/Black 0%; Native Hawaiians or Pacific Islander 0%; White 84%; Other 11%; Two or more races 3%.
Pie chart. Hispanic 26%; Non-Hispanic 74%.
Pie chart. Hispanic 40%; Non-Hispanic 50%; Missing 10%.

slide 19

Patient Follow-Up Survey

• Telephone Survey to a random sample of patients admitted to the hospital in the last year
• Questions on their race/ethnicity/tribal identification which will be compared to the hospital data

slide 20

Focus Groups

• Native American populations served in non-Indian Health Service (IHS) facilities
• Discuss issues and barriers of the collection of tribal identification data
• How should we collect this data?
• How do the communities think this question should be asked?

slide 21

Proposed Data Linkages

• Indian Health Service (IHS) to affirm tribal affiliations and determine misclassification
• Vital Records - Birth and Death Certificate Data
• Emergency Department (E.D.)
• Emergency Management Services (EMS)

slide 22

What are the common issues found in collecting, analyzing and reporting this data?

slide 23

COLLECTION

slide 24

Electronic Health Records

• Unable to collect this information in the hospital's EHR
• Unavailable fields/Not enough fields especially for multiple races
• Incorrect categories for race/ethnicity/tribal affiliation
• Can result in many missing, other or unknown race/ethnicity/tribal affiliation
• Hospitals have to negotiate with the vendors to change their system to be able to collect these new fields

slide 25

Hospital Personnel

• Staff can be uncomfortable asking this information from patients
• Staff lack expertise for data extraction
• Turnover in registration staff and upper level management
• Departments of hospital are not communicating with one another
• R/E/T data collection not a priority

slide 26

ANALYZING

slide 27

Small Numbers Rule

• NMDOH Policy:
• Cannot report a rate or percent with a denominator of less than 20 AND a numerator of 1, 2 or 3

slide 28

Denominator Issue

• Bureau of Business and Economic Research of the University of New Mexico (BBER)
• Calculate population estimates at the state and county level annually and provides population projections every third year
• Widely used calculations by policy, legislatures, traffic planners, school boards and health professionals

slide 29

REPORTING

slide 30

NM DOH Presentation of R/E Data

• Five Categories:
• American Indian or Alaska Native
• Asian or Pacific Islander (Can be split up as long as the small numbers rule is followed)
• Black or African American
• Hispanic
• White
• Multiple race should be reported when available and bridging method explained if applicable

slide 31

NM DOH Vital Records Multiple Race Bridging Methods

• Hierarchical Assignment
• When multiple races are checked, the single race reported is based on this hierarchy

Checked race	Code
Native Hawaiian	06
American Indian or Native	03
Black or African American	02
Filipino	08
Chinese	04
Japanese	05
Vietnamese	12
Korean	13
Asian Indian	14
Guamanian or Chamorro	15
Samoan	16
Other Asian	17
Other Pacific Islander	18
Other	07
White	01

slide 32

Useful References

• Agency for Healthcare Research: http://www.ahrq.gov/
• Aligning Forces For Quality: https://www.rwjf.org/en/how-we-work/grants-explorer/featured-programs/aligning-forces-for-quality.html
• Robert Wood Johnson Foundation: http://www.rwjf.org/
• Health Cost Utilization Project: https://www.ahrq.gov/research/data/hcup/index.html
• NMAC 7.1.27 - Data Reporting Requirements for Health Care Facilities: http://164.64.110.134/parts/title07/07.001.0027.html

slide 33

Comments or Questions?

Contact Information:

Noell.stone@state.nm.us

Nicole.katz@state.nm.us