**Transcript of Cyberseminar**

**HERC Cost Effectiveness Analysis Course**

**Inpatient and Outpatient Costs from DSS**

**Presenter: Jean Yoon, PhD**

**Inpatient, Outpatient, and Pharmacy Costs from the Decision Support System (DSS)**

**October 3, 2012**

**Inpatient and Outpatient Costs from DSS**

**October 3, 2012]**

Dr. Jean Yoon:So today I will be talking about “Inpatient, Outpatient, and Pharmacy Costs from the Decision Support System (DSS) and this is part of our HERC Cyber course series on Cost Effectiveness Analysis. So if you are doing any sort of cost effectiveness analysis in the VA, you may want to use DSS data. 

So this is the outline for today’s lecture. So I will talk a little bit about the other data source in the VA, which is HERC average cost. I will talk about how DSS gets costs and I will talk about several different DSS National Data Extract files. So I will talk about the inpatient data, outpatient data, the intermediate product data and then the pharmacy data.

I will also go over some DSS data issues for research and analysis. So I will talk about some HERC-created files, which are station level and also discharge files with subtotals. I will talk about comparisons with Medicare costs. I will go over some advantages of using DSS data, and I will go over some other miscellaneous issues such as merging with clinical records, outliers and some other issues.

So in the VA there are two main sources of cost data. One is DSS and the other is HERC average cost. The DSS is an activity-based, managerial cost accounting system and it is important to note that it is implemented on a local level. So it is meant to reflect local input producing healthcare.

HERC average costs, on the other hand, are produced by HERC researchers; and HERC researchers assign costs for each VA encounter based on things like diagnoses, length of stay and procedures that happen during the visit. And these cost estimates were designed to be directly comparable to Medicare and other payers.

So before I go into talking more about HERC average costs and DSS, I would like to hear from you about what do you want to use DSS data for. So if you could type into your Q&A panel, then Paul will read off the answers as they come in.

Paul: I am still just seeing weather [laughter], weather stuff so far.

Dr. Jean Yoon:That is right. Now it is starting to come in.

Paul:Pharmacoeconomics was one. VHA, VBA and NCA costs. So VBA would be the Benefits Administration and NCA is the Cemetery Administration. Workloads costs, utilization management. To do a BIA, that is a Budget Impact Analysis, of a future intervention. Oh, I see, here we go. Justifying my existence at work. [Laughter] There is a very frank answer!

Dr. Jean Yoon:I am not sure we can get that! [Laughter]

Paul:Reviewing labor mapping for old and new employees in relation to cost management. Here is the answer: I do not know what I can do with DSS data and was hoping this seminar would help. Estimating average costs for a medical center’s inpatient stays, ER visits, productivity, effectiveness, rural costs versus urban costs, pathology and laboratory costs, inpatient and outpatient costs, pharmacy fill records, find inappropriate workload transmissions related to clinical setups—that is quite specific.

Dr. Jean Yoon:Hmh.

Paul:Clinical outcomes measures. R/T resources used. VHA medical center in VISN CEA. DSS used for nursing outcomes and indicators. Contributing factors which are factored into costs, direct and indirect. Did the speaker just say that DSS costs are intended to be directly comparable to CMS? The – that is, the Medicare – Centers for Medicare and Medicaid.

Dr. Jean Yoon:No, I was not pointing that out. I will talk about that a little bit later in the lecture.

Paul:Mapping of labor. The weather in Cleveland is nice. [Laughter] Oh. Nice question.

Dr. Jean Yoon:That is great.

Paul:Taking a trial of web-based treatment for PTSD versus usual care. Resource utilization by a group of veterans. Assessment of cost savings from an ongoing clinical program. Still hot in Austin. [Laughter] Was that – shall we draw the line there?

Dr. Jean Yoon:Yeah. I think that is great. I think there is a wide variety of interests that people are going to be using the DSS data for. I should emphasize here that I am talking – I am going to be focusing this lecture on the DSS National Extracts. And so I will not be talking about DSS data that the local medical center has, which can be much more information than we get in the National Data Extracts. I should also point out that DSS is not just for VHA, Veterans Health Administration, but is also used for VBA and VCA, the Benefits Administration and the Cemetery Administration. These again get other data from the VA in DSS, not just health data. 

So before I focus on DSS, I will talk a little bit about the HERC Average Costs Datasets. So this is the other data source in the VA that looks at costs and methods that were developed by HERC researchers distribute costs to hospital stays and outpatient visits. And these data were designed to be merged easily with the clinical files.

And so there are three main methods that were used to calculate costs. One is for acute medical surgical stays and was basically an estimate of what the stay would have cost in a Medicare hospital and is based on a regression model using things like DRG and patient age.

The second method is for other inpatient care such as mental health days and rehab and long-term care. And this method primarily uses length of stay to estimate cost.

The third method is for outpatient care and this estimates a hypothetical Medicare payment, which is based on procedure codes which are assigned to each visit.

So to review the HERC average costs, so these cost estimates were designed to be directly comparable to non-VA providers such as Medicare. And the costs are identical for all encounters with the same characteristics. And we will see this is a major difference with DSS data.

HERC also takes the average costs for patients and it creates an average cost for each person in each fiscal year. So if you do not want to figure this out yourself using DSS data, you can get this very easily from this HERC file.

So that was a quick overview of HERC average costs. If you have any more questions about that data source, feel free to ask us at any time. The rest of the lecture will be on DSS data.

So how does DSS data – how does DSS provide VHA cost data?

So as it pulls information from different sources, and this is done at the medical center level. So workload and clinical information are pulled from VISTA, which is the medical records system for the VA; and financial data is pulled from FMS, which is the general ledger, and from PAID, which is the VA payroll system. So the medical center has information on time allocation, so this is where providers and staff spend their time.

And it also has information on relative values. These are the relative resources that go into producing different types of healthcare at the medical center. 

This information gets combined and pulled into the VISN level production databases and some of this information gets pulled out and extracted into the DSS National Data Extract. And so this is what we commonly use for operations and for research.

So you may be curious about how DSS determines cost of encounters and products. The products are the components of an encounter. The product can be like a chest x-ray or a 15-minute clinic visit.

So first, the medical center assigns cost to different cost centers or departments. So a cost center might be something like a primary care clinic versus general medical board. And so it assigns costs based on staff labor mapping and financial data.

It also then assigns the cost of overhead and it gets distributed to direct care departments. So departments that are providing direct patient care.

The products in each department get tabulated. So for example, a primary care clinic would tabulate this whole number of 15-minute clinic visits that it produces in a quarter.

And the medical center also assigns relative values to these products, so the resources that go into producing the clinic visit. So for a 15-minute clinic visit, for example, it would be 15 minutes of provider time. That would be the relative value of that product. And then the unit cost of each product can then be determined.

So to get the cost of the encounters, we take the total products that occured during the encounter times their cost to get the total cost of the encounter. That is how DSS get the costs.

So the different DSS National Data Extract files are the inpatient files, and there are two separate inpatient files. One is called the Treating Specialty file. The other is called the Discharge file. There is an Outpatient Encounter file. There is an Intermediate Product Department, which has both inpatient and outpatient visits in there. There is a Pharmacy prescription level file. I will be talking about these first four files in this lecture.

Second to – I will not be discussing today, although we do have information about it at HERC and through VIReC. Though the Account Level Budget Cost Center has aggregate data. This does not have patient-level data, but it has data at the level of the cost center. So that is available from DSS. And there is also the Clinical Extract, which has more clinical information. So you may want to use a combination of these different data sources in your work.

So first I will be talking about the inpatient files. So the first file is the discharge file. And so what this file has is the care of all patients who are discharged each fiscal year and there is one record for each discharge. And it can include costs if they were incurred in prior fiscal years.

There are some data that are only in the discharge file as it has the date that the patient was discharged from the hospital, it has the total days of stay for the hospitalization and has the bedsection where the patient was discharged from.

So these are just some made up examples of discharge records. So you can see that this is the same person, the same patient, and they had three hospitalizations. So one began on September 24. The second began on October 31, and the third began on August 4. So it has the discharge day, the day that the patient left the hospital, and the length of stay, which is the total length of stay for the hospitalization. It has the bedsection of where they were discharged from. And it has the total cost of the hospitalization.

So the patient may have been treated by – in other bedsections, but you will not see that in the discharge file.

So the other inpatient file is Inpatient Treating Specialty File. So in this file there is one record for each treating specialty, which is the same thing as a bedsection, and it is per month. So there can be more than one record in a month if more than – if there was more than one treating specialty that treated the patient in a month.

Now what this file has, it has all care that was provided during the fiscal year whether or not the stay was over in that fiscal year.

Moderator:Jean, I am sorry to interrupt. We just got a few questions in on Slide 15. What is column FP?

Dr. Jean Yoon:I am sorry. That is Fiscal Period, which is the month. So since October is the first month of the fiscal year, it is fiscal period one. And then November is the second fiscal period.

Paul:So we can say, Happy New Year.

Dr. Jean Yoon:Right. [Laughter] Right at the beginning of October. Okay. So going back to Treating Specialty File, the data that are only in the Treating Specialty File is the Treating specialty, census indicator for whether or not the patient left the hospital, the date of entry and exit from each treating specialty. And so there is no discharge date, so we do not know when the patient was actually discharged from the hospital. We only know the date that the patient left the last treating specialty. There is also the length of stay in each treating specialty. Now if you want the total stay of the hospitalization, you will have to put the records together to figure that out.

So here are some examples from the Treating Specialty File. So again this is the same patient and this is the same treating specialty, which is 15. I am not sure off the top of my head what that is. That could be general medicine or something else. So the TRTIN [treat in] and TRTOUT [treat out] days are the days that the patient entered and left the treating specialty, 15, so they entered on October 1 and they also left on the same day. So the total length of stay of one, and there is a total cost of that one day.

And then they have two more records and it looks like it is a different hospitalization, so they entered two treating specialties 15 on October 31 and then they left on November 11. So there is one record for the last day in October, or October 31, that has a cost assigned to that. And then there is a second record for the ten days that they stayed in that treating specialty in November, and there is a separate cost for that.

So data that are in both inpatient files is the admit day, the day that the patient was admitted to the hospital; the admitting DRG or diagnosis related group. There is a principal diagnosis and there is also an admitting diagnosis.

So this is just to compare the discharge and treating specialty files side-by-side. So this is the same patient, the same hospital stay, but you have two different views. In the discharge file you will find one record and you can see that the patient was admitted on March 15 and then they were discharged on April 12. 

But in the treating specialty, there are three records for this same hospital stay. You can see that the person was in general medicine in March, and then in March they were also transferred to rehab that generated a second record. And they stayed in rehab in April that generated a third record. So you can see that there are three records for this person in the treating specialty file.

So there can be many more records in the treating specialty file compared to the discharge file, as you can see here. Just another example of the same thing. So here is a patient who was admitted at the end of the fiscal year on September 22nd, and then they were discharged on October 8th. So you will find two records for the same patient in the treating specialty file. One would be September in general medicine and the second record will be in October in general medicine. Since October was the start of the new fiscal year, they would be in the Fiscal Year ’04 file. 

So you do have to be careful that when you look at hospital stays that cross fiscal years, that you will have to look at multiple years of data for DSS when you are looking at the treating specialty file.

We are now looking at the outpatient files. So in the outpatient files there is one record per patient per day per clinic stop. 

This is different from the National Patient Care Database (NPCD), which is the clinical database that has more than one record per clinic stop per day.

DSS also has care that is not in the NPCD events file. So for example it has prosthetics care. That is not in NPCD. It has limited clinical information. It has primary diagnosis and it has some procedure codes. It has CPT codes.

Some data that are only in the outpatient files: it has the date of the encounter. It has the DSS identifier, which is also called the clinic stop. DSS uses a “pseudo stop” code for things like prosthetics. 

There is also a flag variable identifying the data source, so some data come from the NPCD, from the pharmacy, prosthetics, Vast CBOC and so on.

Here are examples from the outpatient file. So this is the same patient and this is the same visit day, [inaudible] day. But there are three different clinic stops, so there are three different records here and there is a different cost for each of those clinic stops.

So some cost variables that are in all of the DSS files are fixed direct costs, fixed indirect, variable direct, variable supply, total, and then variable labor category four and five, which is for the providers for physicians and nurses.

There are some additional cost variables that are in the inpatient files. So there are separate costs for lab, nursing, pharmacy, radiology, surgery, and a category for all other. And then under these subcategories there are breakouts for variable costs, fixed direct, fixed indirect and supply if that is applicable.

So there are also intermediate product department files, which also have inpatient and outpatient care, but they have more cost detail than the files I just talked about. These files were released in 2005 and there could be multiple product departments that provide care for each encounter. So what the file has the cost that is incurred in each product department. 

So the inpatient file is similar to the treating specialty file. It has a monthly record, except it is per patient per inpatient product department. In the outpatient files there is one record per patient for each outpatient product department.

So here is an example of the Inpatient Intermediate Product Department files. So this is the same patient and this actually the same treating specialty, you can see by the TRTIN and TRTOUT days. But there are three different product departments under this treating specialty, there’s psych MD bed day, there is psych-neuropsych lab, and there is occupational therapy. So you can see we can get very specific costs here. We get different cost breakouts for each of those product departments.

But this file generates a lot of records compared to the other inpatient and outpatient records that I talked about. So this is mainly useful if you want cost detail at the level of the product department. 

Paul:So, Jean, while we are still on the treating specialty file, you had previously put up a slide that had something about the census indicator.

Dr. Jean Yoon:Mm hm.

Paul:And someone asked what is that census indicator all about. What is the difference between census equals Y and census equals NO (n).

Dr. Jean Yoon:Okay. Census indicator indicates whether or not the patient left the hospital.

Paul:So. Yeah. And I think it only applies, right, to the end of the fiscal year. So if you have a September record and the patient is still in the hospital on the last day of the fiscal year, then that census indicator is just telling us they are hospitalized. So basically the census indicator is, was the patient hospitalized on September 30 at the fiscal end of the year? And so the DSS is going to build a new set of records for the next year and that tells us that they are still in the hospital and there will be a record for them in October also.

Dr. Jean Yoon:Right. And census equals no for Fiscal Period 1 because they were not in the hospital on October 30 – October 31.

Paul:And then someone asked, is it possible to determine the cost of a particular surgery type and whether it is inpatient or outpatient? So this kind of gets back to what your – your intermediate product stuff, I guess, right?

Dr. Jean Yoon:Right. So if it occurred during an inpatient stay, it would be in the inpatient files. If it occurred in the outpatient visit, then it would be in the outpatient files. So if you were interested in surgery, there are several different surgery product departments. You would go in and search for patient records.

Paul:So there is – the inpatient would have a record for the cost they incurred in one or more surgery departments and so would an outpatient.

Dr. Jean Yoon:Right. Right.

Paul:So the way to drill down into the costs that are surgery from other costs associated with the stay is to get the breakdown by department in the IPD Extract. And then there was one – someone who wondered if you might speak a little more slowly.

Dr. Jean Yoon:Okay. Sure. Okay. So now turning to the DSS pharmacy files. This is the DSS Pharmacy Extract file. And for outpatient records, there is one record per prescription or supply per person per day. For inpatient records, there is one record per person per day.

DSS will sometimes group two prescriptions into one record if they are for the same NDC—NDC is just the unique drug code for a prescription—so if it is for the same NDC and the same person on the same day.

So some of the variables that are in the DSS pharmacy files are medication information. There is the drug name; the NDC, which is the drug code; there are formulary indicators; and there is also the VA drug class. There is some dispensing information such as the fill dates, the dates the prescription was filled. It has the quantity dispensed and it has the days supplied. There is some patient information, such as the patient scramble, the date of birth, gender and age.

There is also the ordering provider. There will be a provider ID for who ordered the prescription, and also the provider treating specialty.

So if you want some clinical information and you want to be able to link that to the DSS pharmacy record, you can do that by using the patient scramble and their visit day.

So the cost data that is in the pharmacy file includes direct labor, indirect costs of the pharmacy department, and supplies. So if you want the total cost of a VA prescription, it is the actual total cost plus the dispensing cost. So that includes all labor and supplies.

So if you have ever worked with the DSS pharmacy files, you probably noticed that there are negative records – negative values for cost. There can be returns to pharmacy. So if, for example, the patient left the hospital, and did not pick up their prescription. It may have gone back to the pharmacy and come back as a negative cost.

So you may be interested to know about the patient’s copays for drugs. The VA charges copayments and they depend on the patient’s income and disability percentage. The rules and eligibility levels change year to year. You can find this on the VA Internet.

DSS does not show the patient’s copayment. What they show is the VA’s expense for the drug.

So if you are interested in getting the patients’ copayments, you’ll have to figure out what their eligibility is and then find the copays that are assigned to eligibility levels.

The Medical Care Cost and Recovery (MCRR) files could show reimbursement from private insurance, if it was collected for those drugs.

Now that I talked about the different files, I am going to talk a little bit about some issues about using DSS for research and operations.

So HERC has created some DSS files. There is – one of them is the Station Level Cost Data Set, which begins at Fiscal Year 2002. And this has the annual cost and total utilization, and it is measured by either inpatient days or outpatient visits for different HERC-designated service categories as there are 13 inpatient categories and 12 outpatient categories. So what this file does is it reports cost and utilization and it has one record per service per station (STA3N) per fiscal year.

So for example, you might want to know the total cost for mental health outpatient care at the VA Palo Alto for Fiscal Year 12. So you would – you could get that from this DSS Station Level File.

Another file that HERC creates is the DSS Discharge Dataset with Subtotals. So as we saw earlier, the discharge file only has the discharging bedsection, but it does not show what other treating specialties were involved in the care of that patient during their hospitalization.

So HERC started to create this discharge file beginning in Fiscal Year 2007. It is functionally identical to the DSS Discharge National Data Extract except that it has additional fields for cost and length of stay for different types of inpatient categories, such as acute medicine, psychiatry and nursing home. And I believe there are 13 categories that you could look at here.

So rather than trying to work with the treating specialty file yourself, you can go in and use this HERC-created Discharge Dataset, which has more information than the Discharge National Data Extract file.

So if you are working with DSS data, you may be curious about how it compares to Medicare costs, and you should be aware of some differences in DSS and Medicare costs. 

So for physician services, it is included in hospital costs. In DSS it breaks it out separately under Variable Labor costs or under Variable Labor 4 and 5. And under Medicare, these physician services are excluded from hospital costs.

For indirect costs, DSS includes VA central office and national operation costs plus hospital administrative costs under indirect, whereas Medicare only includes hospital administrative costs.

For capital costs, these are excluded in DSS, but they are included in Medicare.

So these are just some of the differences between DSS and Medicare, if you want to compare costs across the system.

There are some advantages of using DSS over something like HERC Average costs. So DSS cost reflects facility differences in productivity, [inaudible] fees and economies of scale between medical centers. DSS has pharmacy data. It also has community and state nursing home stays in the outpatient file.

DSS is also an activity-based method and is the official cost managerial accounting system for the entire Department of VA. So because it is an activity-based method, it is also believed to be more precise than other methods of estimating cost.

So this is just a graphic to show you DSS relative to other methods on how precise it is in measuring costs. DSS is considered a direct measurement method, so it is considered very precise. HERC Outpatient Average Cost methods use a pseudo-bill that is a little bit less precise. The inpatient HERC cost calculating medical/surgical costs use a clinical cost function, so it is on the less precise end of the scale. And for Cost Estimate we have mental health and long-term care costs. Use an average cost per visit, so that is considered also less precise.

So if you are using cost data from DSS, you may want to merge in data with the Utilization files to get more clinical information. This just shows you how easy it is to merge in these DSS data with the VA utilization data.

You can see in the top row, so if you want to merge in the PTF Main files with the discharge data from DSS, it is relatively easy because there is one record for each discharge.

If you want to merge in the outpatient DSS data with the NPCD outpatient files, it is a little bit more difficult although still relatively easy to merge in DSS. The DSS outpatient data only has one record per patient for each clinic stop, whereas in the NCPD files you can have more than one record for each clinic stop for each patient.

And DSS data also has records – also has data that comes from other sources outside of it, PCD. If you want to merge in the DSS treating specialty files with the PTF bedsection files, it is a little bit more difficult merging these records. So these files use different rules for putting – for entering in the enter and exit dates for each treating specialty. So you may have to search for one or two days within each treating specialty stay in order to merge in these records.

So this is just something to consider if you work with both utilization and NCSF data. 

If you have a [overlapping voice] ...

Paul:Jean, if I might interject here. So a person previously asked about how would you find out about surgical costs? And so they might be interested in knowing about a particular kind of surgery. And they might identify those surgeries by using the NPCD outpatient file, which is a SAS dataset, which has all the CBT codes, all the procedure codes, and tells you what kind of surgery it is. The DSS data do not have all the CBT codes. They just have one CBT code. We think that is going to change in the future. So that would be a reason to merge these files, right? You are going to identify your surgeries in that medical SAS NPCD file ...

Dr. Jean Yoon:Mm hm.

Paul:... and then you want to know what the cost is. So you get the cost from the corresponding record in DSS.

Dr. Jean Yoon:Yes. Thanks for making that point. So there is very limited clinical information in this – in these DSS records. So mostly you’ll want to go to the VA Utilization files to find clinical information such as diagnoses and procedures. You can then merge in these records with DSS cost data to get the cost of that care.

There are just some points about outliers in DSS. Users should look for cost estimates that are unexpectedly high given the characteristics of that care. There can sometimes be a mismatch of cost and utilization that can result in unit costs that are very high or negative. 

But DSS does do a lot of quality assurance around their costs. There was an audit that found the costs in DSS generally agreed with the general ledger. And annually extreme high outliers are identified and corrected when the DSS national data extracts are built.

I want to point you to some DSS resources if you start to work with DSS data. There is a HERC Guide on using DSS data for research and this is on our website. 

There is the DSS Program Office Website. This is an intranet site and has a lot of detailed information about how medical centers calculate costs at the medical center level and also other information about DSS. So there are SAS and SQL files available at the Corporate Data Warehouse for Fiscal Year 05 and beyond for all the National Data Extract files that I talked about today, and for other ones that I did not talk about.

So in the past DSS data have been available at the Austin Center, but from what we understand, Fiscal Year 12 data will be posted to the Austin Center in November. But it is expected that all DSS files will eventually be removed from Austin in January 2013. So you will need to access that data at the Corporate Data Warehouse.

So if you are not interested in looking at patient-level data but instead you just want summaries of data, you can get that from the DSS Reports Website through that intranet site that is available from the VSSC, but as summaries of DSS data and as documentation of DSS and descriptions of new DSS datasets.

So HERC has several guidebooks on using DSS. This is a link to the HERC website. So we have a *Research guide to DSS*, which was updated in 2010. We have a *Station Level Cost Dataset* guidebook. We have another guidebook which describes our DSS *Discharge Dataset with Subtotals for Inpatient Categories of Care*. Then we have separate guidebooks that describe using the *Intermediate Product Department Files* research. 

So VIReC has a guide that looks at pharmacy data in both DSS and PBM. So this is the link to their website. And HERC produced a technical report which compared costs from DSS with the Pharmacy Benefits Management Database. So you can take a look at that if you are interested to know more about that.

And then if you are still interested in using HERC average cost, we do have some guidebooks describing HERC average cost. So we have one that looks at inpatient care, another that looks at outpatient care, and another that describes our *Annual Person Level Cost Dataset* for data that was created beginning 1998 all the way up to 2010.

So here is a reminder about the next classes in our HERC course series. So next week’s will be sort of a miscellaneous presentation about various topics that cover “Sources of VA Care Cost and Providers,” and then on the 24th there will be a lecture about “Medical Decision-Making and Decision Analysis” by Jeremy Goldhaber-Fiebert, who is a professor at Stanford.

So that is basically my talk for today. If you have any other questions, Paul and I will be happy to answer them right now. Just type them into your Q&A panel.

Paul:So there was a question about slide I believe it was 34 that we got back. It is pretty specific.

Dr. Jean Yoon:Okay.

Paul:Let me see if I can find that.

Dr. Jean Yoon:Okay.

Paul:It said, what is Variable Labels 4 and 5? Okay. So it is ...

Dr. Jean Yoon:VL 4 and 5 is Variable Labor 4 and 5 which is for physicians and nurses. So if you want the cost of provider services, you can get that from DSS.

Paul:Right. And so that is a particular type of labor. Do we remember what VL 4 and 5 are? I do not. But it is in our guidebook.

Dr. Jean Yoon:Yeah.

Paul:Somebody asked if there are costs for telemetry appointments. They come up in inpatient data, but these are remote measurements, I think. Do you know anything about this?

Dr. Jean Yoon:I am not sure what telemetry is. If it’s the Product Department or if it’s the clinic stop in an outpatient visit, then there would be a separate record for that. You can search under the clinic stop or the Product Department for those records. There is a procedure code that is associated with that type of care and you could search for procedure codes in the Utilization data and link that to DSS data.

Paul:And then people have asked about how do you get permission to access DSS data? And in general and in the true Social Security general data in particular?

Dr. Jean Yoon:The DSS uses a scramble. It does not use the true Social Security in the National Data Extracts. If you do want true SSN, you will have to file for an outpatient to get that data. So your – in the past, DSS data have been in Austin when you filled out your 9957 form to get data at Austin and you would put down the code, the DSS-specific code to access DSS data. This – we are now using VINCI to access data such as DSS. You need to apply to get access through DARTS. I do not remember what the acronym stands for, but you file a request through DARTS to get access to whichever dataset you are interested in. And you can then use this data through VINCI.

Paul:Which – I would advise people – I was just saying, Jean, the people could go to the VIReC website, www or vaww.VIReC.va.gov. So that is our sister – there we go. Does it have research in it? My – okay. I guess I had forgotten that. The – and they have those – not only the researchers are guides, but they have a new users’ toolkit that will direct you to the VA websites that – where you get the instructions on how to apply for permission. And the rules are – there are two sets of rules, one for researchers and one for operations customers.

Dr. Jean Yoon:So I am not sure about the DSS reports website, whether you need to go through DARTS and all that. In the past you could apply for access to get DSS reports and data and then go on to the website. And they could give you some quick tabulations on the website to get total costs in a medical center or things like that.

Paul:And someone posted a correct observation that the DSS website is no longer on the VSSC server, that there is a separate DSS reports website. However, if you do go to the VISN Support Services Center website, it will direct you to that, at least for a while longer. So we do need to update our documentation here. They have uh split that off. And we are a little bit fuzzy about it.

So it used to be that you needed to get a certain functional task code to access the DSS reports. A functional task code is a level of permission at the Austin Technology Center. But now since we are switching from that Austin Technology AITC to the VINCI, we were – we do not really know how that is going to affect how you get that access to this reports website.

And then there was a question: is DSS available at CDW now?

Dr. Jean Yoon:Yes. So there is Fiscal Year 05 data and beyond at the Corporate Data Warehouse.

Paul:To get diagnosis as it relates to the cost per patient, where would I find that data?

Dr. Jean Yoon:So if you want diagnosis information, you would need to go to the Utilization Files. For inpatient, say, you would need to go either to the treating specialty file or the discharge file. If it was for an outpatient visit, you would have to go the NPCD, the National Patient Care Databases, and you could search for whatever diagnoses you were interested in. You would then have to link the record for that patient, that visit, to DSS. You would have to link it by patient scrambles saved as a medical center and a clinic stop. For example, if it was an outpatient visit.

Paul:And then someone said: I have a cohort of 1,000 patients that I am interested in obtaining all inpatient and outpatient costs for a specific time frame, 1996 to 2010. Is it possible to match these patients I have to their specific records in DSS?

Dr. Jean Yoon:Yes. But I believe DSS began in 1999. Is that right, Paul?

Paul:Yes. But the first year is problematic. So it would be better to say it began in 2000.

Dr. Jean Yoon:Okay. So you can get data up to 2010. So if you wanted costs for a cohort of patients, you would just get their scrambles and then search all the records for those patients’ scrambles and then you could aggregate the costs for each patient over that time period. But just be aware that you would have to make sure that you get records from inpatients and outpatients. You would not necessarily get the pharmacy files unless you wanted prescription level data. You could get the drug data from the outpatient data. But just be aware that you would have to get the data from these multiple data files.

Paul:And I would just observe the HERC cost data also start in 1999 and HERC does have a technical report that gives advice on how to estimate costs for earlier years. But I think that would be very hard to do at this point, because I think it relies on datasets that are no longer easily accessible—cost datasets that are no longer easily accessible. So that may be pretty problematic. And another approach would be for some of these old records or even for the whole study is to come up with some sort of way of assigning costs based on average cost per visit or average cost per day of stay or discharge or something like that. It is going to be hard to assign costs to those old records.

Dr. Jean Yoon: That is right. I see that the large cohort you may have many records.

Paul:Well, 1,000 patients. So they ... and then someone was – a couple people let us know that VL-4 is physicians and dentists and VL-5 is contract labor. And are there costs recorded for Telehealth or the unique indirect costs of Telehealth, for example data transfer?

Dr. Jean Yoon:Well, there are some Telehealth – clinic stops in the outpatient records. So for example I think there might be one for like mental health. For example, the mental health Telehealth is a separate clinic stop. So you could get the costs of those visits. There are several others, but I do not remember what they are off the top of my head. But if you go to the DSS website, they do have a list of all the identifiers, DSS identifiers or clinic stops, and it should list all the different clinic stops that they have, and some of them are Telehealth.

Paul:Someone wants to know if they have – already have DART approval can they get the HERC data. And so if their DART approval – let me answer that. If their DART is to work with data at the Austin Information Technology Center, the HERC data are there. The HERC data are not in the Corporate Data Warehouse yet. We are still negotiating with the various data custodians and privacy officers and whatnot about how we are going to do that.

Dr. Jean Yoon:But the goal is that the HERC datasets will be available at the Corporate Data Warehouse eventually.

Paul:Yes. Hopefully within the next six months. But right now they are available at Austin on a ShareDrive and we can help you get to those – get to them there. And then it says – somebody said – this is more of a comment, a helpful comment: “Telemetry visits are found in the field where inpatient visits are named. Hmm. Not sure I understand that. Such as where it might say ‘General med internal’ it says Telemetry. Telemetry is for remote measure of cardiac functioning, but it is in the inpatient table.” Well, we will have to ask – and ask her – well, maybe we ought to link our questioner up with that person that seems to understand this more than we do about telemetry.

Dr. Jean Yoon: Right.

Paul:Where do we go to find data definitions of DSS variables?

Dr. Jean Yoon:So that is actually available in our different guidebooks. So in the *Research Guide to DSS National Cost Extracts* we actually have all the variables. They are listed in these separate files and we have definitions, descriptions of these variables. Just go to our website in the publications. You can look up our [inaudible] and then find all these listed. So we have data definitions in each of these guidebooks.

Paul:And I guess we should also mention that there is a DSS website and they have their own guides to these national data extracts, which sometimes are more detailed but sometimes are more terse. So we have tried to create something that is – has some added value in terms of description.

Dr. Jean Yoon:Right.

Paul:But there are those reference works.

Dr. Jean Yoon:And we have created guidebooks for certain files, but there are many other DSS files that we do not describe in our HERC guidebooks. So you may want to go to the DSS, national data extracts section, for the guide to see a list of all the DSS extracts that are available. And they do have descriptions of files and the variables that are in each file.

Paul:And one of the attendees reminded me that there is a surgery, a DSS Surgical Extract and – which we have not documented, and we are not quite sure what the criteria are for records to go into that surgical extract. Just the cost data that are in the surgical file, and there are a bunch of other files that we have not alluded to here, but they would be – the costs would also be reported in the various inpatient and outpatient files. So in that sense, they are redundant. But it might be another way of drilling down to figure out about surgical costs. So that surgical file is – I think we just have in our guidebook a description of what it is and that – but you would have to go to the DSS site to find a little bit more about the variables.

And then: Do you have a timeframe for DSS data moving to VINCI? Sigh. [Overlapping voice].

Dr. Jean Yoon:The data are already there.

Paul:Yeah, but the question is, when are they stopped being available at Austin? Maybe that is the real – what the sigh is about. That is, at the Austin, the current mainframe system.

Dr. Jean Yoon:The information that VIReC put out in their latest newsletter was that all the DSS data would be removed in January 2013. So we would not be able to get DSS data there beginning January 2013.

Paul:You will have to go to VINCI after that date.

Dr. Jean Yoon:Right. 

Paul:And then a question: In what circumstances would you rather use the HERC average costs versus the DSS costs?

Dr. Jean Yoon:So HERC costs they estimate costs and they are consistent for when the hospital stays and outpatient visits have the same characteristics. The costs will be the same. Whereas DSS costs are meant to reflect local input to producing that care. So the same visit may not cost the same at the different medical centers in DSS, whereas they will cost the same using HERC average costs. Those methods estimate costs to do that. So as I showed earlier on the slide about precision, DSS is a direct measurement method, so it is believed to be more precise. However, if you want costs to reflect the amount of utilization and not so much the local input using that care, then you will want to use the average costs.

Paul:Or it might be useful to think of the HERC costs as kind of a standardized cost that might be useful if you want to make generalizations about the healthcare system and not so much what happened at any particular site. So that might be a use of it. What would’ve it cost Medicare to have bought that service in essence?

Dr. Jean Yoon:Right.

Paul:And then the question is: Are the DSS data in the Corporate Data Warehouse different from the local DSS data?

Dr. Jean Yoon:Well, I do not know much about the local medical center DSS data. Do you, Paul?

Paul:Yes. So I would say the following is that in terms of the cost, the data that are in the Corporate Data Warehouse are derived from the local production systems data. And so the only reason to go to the local data would be to find certain cost elements that are not in the Corporate Data Warehouse. That said, it is pretty hard to do. To get access, you would have to go to your site team at that site; and if you try to imagine that – you have a study that is at multiple sites, that could get – or even a national study, that would become very tedious or even impossible to get them to run that job for you.

So the real question if – so DSS is more than a costing system. So there are some clinical applications that could only be done within DSS. There are some things like analyzing the cost per day of stay that might only be done in the production system. You could also drill down to find out the exact number of each type of intermediate products that are used to produce an encounter in the DSS production system—these very fine levels of detail that are not in the National Data Extracts just make the extracts so big.

So for example, if you wanted to know how many lab tests of a certain type were provided to a particular patient during a particular stay, that could be found in the DSS production level data. But I think the NDEs, that is the National Data Extracts, that are in the Corporate Data Warehouse have so much data in them that it seems unlikely to me that any ordinary analysis is going to need that production data.

And moreover, I would look real hard to make sure there is not any national data extract that meets my needs before I would go down that route just because it would just – it is going to be hard to get the local sites to do that for you.

And then someone commented: Be aware that Telehealth clinic mapping of resources has been problematic, so be careful in how you use the data.

Dr. Jean Yoon:Okay. Your voice broke up when you were saying that. Did you say Telehealth?

Paul:Telehealth. Yeah, I am sorry. Telehealth clinic mapping has been problematic—resource mapping has been problematic. So they were just saying that the Telehealth data, you need to be critical of it.

And I think the little we know about that is there has been some – so one issue has been that the definition of a Telehealth encounter has gotten – although it is clear what represents an encounter – what policymakers regard as a Telehealth encounter, that sometimes the people who enter data have been a little bit sloppy. And so some routine telephone care gets called an encounter when it should not be called an encounter. And so that has been kind of a data problem.

But I think there are other issues, too. This interesting mapping of resources to Telehealth could be an issue, too.

And then there is a question: Are DSS data in CDW tutorials? Perhaps schemas that identify DSS in CDW.

I do not think either one of us knows the answer to that.

Dr. Jean Yoon:My guess would be no, that they do not have tutorials for DSS data in there.

Paul:So I did not know there were CDW tutorials. I would like to learn about them. There are some and we do not know about the DSS schemas in CDW, but presumably they are being developed. We understand that the way that DSS data appears at CDW will do away with the cumbersome way of dividing the datasets up by VISN that we now have, and by year, in the DSS SAS data extracts that are at Austin. So rather than having one – so right now if you want to look at outpatient data saved nationally for five years in DSS at Austin, you have got to look at 21 files, one for each VISN for each year for five years. So that is what, 105 files. So the way it will be in CDW is there will be just one DSS outpatient table. So it should be easier. The schemas should be less complicated.

Another question is: Do DSS and the average cost data include fee-basis costs?

Well, this is a sucker. This is one of our colleagues. This is a softball lob at us. [Laughter] 

Dr. Jean Yoon:So no, fee basis is care that is provided outside the VA through a contract. So that care is actually in a separate dataset called Fee Basis. And so that – there is an annual file for that. And the record may not be – the records come in slowly over time because they come in as they get paid out to the providers. So if you are looking for care that was provided in Fiscal Year 11, the records may not be complete until one or two years later. But there is a separate file for that called Fee Basis and we do have a guidebook on that dataset, and we do have some periodic cyber seminars using that dataset. I believe we will have something later this year on Fee Basis.

Paul:How does the HERC guides relate to the new CDW – DSS data at CDW?

Dr. Jean Yoon:That is to be determined. We are in the process of updating all of our guidebooks, and we want to make them accurate to reflect access on CDW and VINCI. So we do provide some basic description about getting DSS data through VINCI. I myself have not looked at it in some time, so I cannot give you a detailed description of what we have in there. But we are currently updating our research guide, which was last updated in 2010, and we hope to have a new version in the next few months posted to our website. And we will have as accurate information as we can find about VINCI and DSS.

Paul:So we think that everything that says in the resource guide is going to continue to be true, except that the – it is no longer going to be SAS files with you having to know which file of the data that you are looking for is in, that there was – like I said, rather than 105 files for five years of data, you will just go to one table. So the only thing that really will become obsolete, so far as we know right now, is that whole – which record is in which file section of the guidebook. And that that would just not be necessary. You will just need to know the name of which table to find the data in.

Are there VA restrictions on publishing VA costs?

Dr. Jean Yoon:There is – not that I know of.

Paul:Well, we should have – yes. So there is supposed to be – so something I think we sign – a training we took. So the DSS – to use DSS data, people are asked – have been asked – and it is an interesting question, exactly how this happens in the regulatory process now or what people agree to. But not to give out any information on the costs of any particular product at a particular site. And the idea is that we – so we do not want to publish to the public the cost of a specific product at a specific site. And a specific product could be like what is a hospital stay involving a CABG. Or another particular DRG. It could be what does it cost us to do a specific lab test, that sort of specific – at the national level it would be okay, but at the level of a particular site, not. And the reason is because it could interfere with the ability of VA managers to negotiate contracts. So a lot of sites are involved in make-or-buy choices and if somebody says this is what it costs us to build it, well, then it would sort of undercut the ability of our managers to conduct their negotiations. So when I signed up to use DSS, I had to sign a nondisclosure agreement that said this. And I – so I am a little surprised that maybe you have not yet, Jean. Maybe you did and you just do not remember.

Dr. Jean Yoon:Maybe. [Overlapping voice]. [Laughter] 

Paul:But anyway, we do not want to do anything that compromises the ability of VHA to do its business. So. And that is basically the deal.

Can one determine the cost of a certain surgery? For example, for three years, and project its benefit for the future? Or does one have to determine the cost longitudinally? 

Hm. I am not sure I understand that.

Dr. Jean Yoon:[Overlapping voice] ... surgery happened at one time and then you could measure that cost by going into the inpatient file or outpatient file, finding the cost of that surgery. If you wanted to look at the benefits, you would probably want to measure something like outcomes like quality of life or other – sort of other functional outcomes with survey data. You could look at their subsequent use of healthcare services after the surgery like how often they came in for primary care and things like that to look at the cost of that patient over time.

Paul:Yes. So I would also observe there is someone else who asked about: Are these data inflation adjusted? 

And no. Every cost estimate in both the HERC and DSS files, the HERC average cost and the DSS files, are in the year in which the service was delivered. And there is a little wrinkle in this – in DSS is that if a service is delivered over several years, for example a long-term nursing home unit stay, then the costs are expressed in the year of discharge. And so where this could be significant is if someone had a multi-year stay and the costs are expressed in – the costs of the discharge year. So in a certain sense, that particular kind of stay would be – reflect changes because of inflation. It is not entirely nominal. But that is a – that is kind of a rare case.

Dr. Jean Yoon:Any final questions? We are getting ...

Paul:Someone noted that on their – if you run a DSS report, it has a notation, “Government use only.” And I do know that if there may be some disclosure agreement when you use the DSS report site or some sort of thing you click about what you are going to do with the data.

Dr. Jean Yoon:Okay.

Paul:I think we have used up the hour. I would encourage anybody who has a – any remaining questions to get a hold of us at the HERC email address, which is simply HERC@va.gov and we will do our best to answer it if we have overlooked anybody’s ... and then the person who had the comment about Telehealth, someone else asked, can I – can we contact you? So maybe the person who gave us the comment about the problems with the Telehealth cost data, if you indicate your willingness to be contacted or not, that would be great. In the question box.

Moderator:Or they can just email into cyberseminar@va.gov and I can help out with that. 

Paul:There was a question about how to adjust for inflation. I would direct you to the HERC website. But we use the Consumer Price Index for all goods and services and not the Medical Inflation Adjustment. But that – see the – it is not really about DSS. But we do have a Frequently Answered Question on our website like that.

Moderator:Okay. Okay. Sounds good. And with that, thank you, Jean, thank you, Paul. We very much appreciate the time you have put into this today. Thank you to our audience for joining us today and we look forward to seeing everyone at a future HSR&D Cyber seminar.

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