Looking for the 'sparkle' in the CROWN (web)

CROWNWeb, a data collection system for the ESRD program that was years in the making and mandated in the 2008 update of the Conditions for Coverage, debuted in June after numerous pilot tests and troubleshooting. Six months later, the system still has a long way to go before it can deliver reliable patient data to the Centers for Medicare & Medicaid Services.

After hearing from the renal community about ongoing technical problems and system overloads while trying to hit a Nov. 30 deadline for data submission, CMS agreed to relax the deadline "until further notice" while it tries to correct the problems. The Nov. 21 letter from Theresa Casey, Director of the Division of ESRD Population and Community Health Quality Improvement Group for CMS, tells providers to keep on working toward the November deadline, but that "noncompliance does not have adverse consequences at this time."

Casey was reacting to a letter sent by the National Renal Administrators Association on Nov. 14, asking for an extension. In the letter to Casey, NRAA president Katrina Russell said facilities are now submitting upwards of 30,000 files per day through the NRAA's own Health Information Exchange portal to CROWNWeb. But extended delays and service outages to get the data from the HIE into the CROWNWeb system have occurred, and "severe" limitations in the throughput capacity of CROWNWeb has been a problem. "At this point we collectively have so many files sitting in our systems that we have instituted emergency methods and have asked some of our submitters to hold off sending more files until CROWNWeb can catch up with the pent up volumes,"Russell wrote.

In it most recent update to members, the NRAA noted several of the problems with the CROWNWeb system:

An attempt by CMS to improve the bandwidth of their system so the NRAA’s HIE could push more data to CROWNWeb has not occurred. As a result, the HIE has to queue large amounts of data and slowly feed it into CROWNWeb.
The HIE technical staff has asked for 24/7 access to CROWNWeb to help facilities meet the Nov. 30 deadline, but no decision has been made yet on availability.
HIE end users continue to experience CROWNWeb processing issues that generate data errors. The errors are not provider- or E H R vendor-driven, but occur within CROWNWeb.

In relaxing the deadline, Casey said the agency still expects providers to try and meet the goal of sending completed data to the CROWNWeb system. "In the coming weeks we will begin a new phase of data analysis to assess the completeness, correctness, and validity of data entered into CROWNWeb," Casey wrote. "We will take a snapshot of CROWNWeb data on the first Monday of each month to analyze the data in the system and to assess data submission progress."

A dismal history
The intent of CROWNWeb (which stands for Consolidated Renal Operations in a Web enabled Network) was to create a vast network of patient treatment data to be used by CMS to evaluate outcomes and ultimately give patients a clear picture on how the quality compares among clinics. The data would eventually be used to make the agency's Dialysis Facility Compare website more robust, similar to efforts CMS has made with publically reporting quality data from nursing homes and hospitals. The data in CROWNWeb would also be used to help the agency develop quality measures in the future for the Quality Incentive Program (CMS used early inputs of data from large dialysis organizations during the CROWNWeb pilot phases to propose a quality measure for hypercalcemia in the 2015 QIP).

While the collection system has lots of promise, the technology to bring it online has been fraught with problems. CROWNWeb has been around in different iterations for over 15 years; contractors have been changed to fix flaws in the design and to modify software. The agency tried to launch it in February 2009, but a unified, renal community protest convinced CMS at the last minute to delay the launch and conduct small pilot tests instead to make sure the system worked in real-time. That testing continued until earlier this year, and CMS launched CROWNWeb in June with their fingers crossed.

Despite the testing, problems cropped up almost immediately. CMS agree to extend deadlines in July for facilities trying to make the system work.

With this latest memo outlining a plan to regroup on CROWNWeb, and an easing of the deadlines, CMS deserves credit for understanding that most of these issues are within the agency’s prevue. For facilities, CROWNWeb is an unfunded mandate; notably, it places the heaviest burden on small providers, who cannot batch process and who have the fewest resources to hire extra personnel.

It would seem that more "dry runs" for CROWNWeb would have been in order before going live, but CMS is clearly trying to work with the community to resolve the problems. And bring some sparkle to the crown.-by Mark Neumann