The administrative burden of the CROWN

By Bill Peckham

The Consolidated Renal Operations in a Web-based Network (CROWN) system is due to come online in less than two months, February 2009. This is a new way to collect clinical performance measures (CPMs). The Balanced Budget Act of 1997 required Medicare (CMS) to collect provision of dialysis quality measures - CPMs. CMS used the National Kidney Foundation's Kidney Disease Quality Initiative Clinical Practice Guidelines to devise sixteen CPMs, including measures of HD and PD adequacy, anemia management and fistula use.

Right now the data is collected through sampling. 5% of all patients, selected at random, have their data submitted. The new conditions for coverage provide for the CROWN system to replace the sampling system. The CROWN system is meant to collect data from every patient. The goal is good, however, for reasons that are not entirely clear CMS is allowing only the three largest dialysis companies to submit the data electronically. All other dialysis providers must submit their data by hand - basically a nurse has to read one computer screen and then enter what he/she reads into a form on a website.

This letter (PDF from HDCN) from Keith Mentz, President of the Renal Administrators Association, to CMS was written back in September. Since this letter was written CMS has done nothing to indicate that they even hear the concerns, let alone that they are working to address obvious problems. CMS is providing inadequate training - their training web site has yet to come online (maybe it'll be up sometime next week). In the face of these problems there has been no communication from CMS.

This continues a pattern of silence. The decision making process has been opaque for the last several years. It would seem that communication with CMS is limited to paid full time government liaisons – people who only large dialysis providers can afford to have in Baltimore and DC. People who are at hand when regulations are being written and implemented. There are numerous problems with the implementation of the CROWN.

My understanding is that because this is a federal database the individual doing the data entry has to have authorization, this requires clearance from Homeland Security (I find it disconcerting that working as a dialysis nurse earns you a Homeland Security file). I do not want a dialysis nurse to have to spend time doing data processing. The facility operating licenses are at stake, this data entry has to be done and it'll be nurses mostly doing the tedious task. I've given up writing CMS.

With less than two months until the CROWN is launched, I am writing my Senators - Senator Murray and Senator Cantwell. Both of my Senators have a record of supporting people on dialysis. I hope my Senators can press CMS into taking responsibility for their system's inability to accept electronic data from small providers. The small providers have the ability to submit the data electronically, until Medicare is prepared to accept the data from all providers in electronic form small dialysis providers should continue to be allowed to submit a 5% data sample. I want nurses to do nursing, not data entry.

The leadership at CMS has short timers syndrome, they're running out the clock on their stint running an important agency. Leaving the CROWN mess for the next administration is not in the interest of patients. It is too bad that this is how they will finish their stewardship of the dialysis program. The new conditions for coverage make a lot of sense and seem very well thought out. The one thing that is clearly stupid is the implementation of the CROWN. There is still time to do the right thing.

Comments

[Zach]

Hopefully with a new administration that actually understands that we are in the 21st century, corrective measures will be implemented.

[Keith Mentz]

I want to thank Bill from speaking from a patient's perspective on CROWNWeb. Many still do not realize the burden being placed on the smaller renal providers who can least afford the cost of manually submitting data. Any calls to your Representatives or Senators will help and if you need any assistance with understanding this issue please call the National Renal Administrators Association (NRAA)and we will help you understand that CROWNWeb is not ready for prime time.
Keith Mentz
President - NRAA

[Dori]

Keith, what reason is being given for smaller providers not to be able to batch data & send it electronically as the larger ones can do?