Stroke/VTE Quality Measure Build for Meaningful Use Stage 1

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1 Stroke/VTE Quality Measure Build for Meaningful Use Stage 1 Presented by Susan Haviland, BSN RN Senior Consult, Santa Rosa Consulting

2 Meaningful Use Quality Measures Centers for Medicare and Medicaid Services (CMS) 15 clinical quality measures Hospital must report clinical quality measure results 7 Stroke measurements 6 Venous Thromboembolism measurements 2

3 Stroke Measures 2 and 3 Stroke Measure Stroke 2 NQF 0435 Stroke 3 NQF 0436 Details Title Ischemic stroke discharge on anti-thrombotics Description Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge Title Ischemic stroke anticoagulation for atrial fibrillation/flutter Description Ischemic stroke patients with atrial fibrillation/flutter who are prescribed anticoagulation therapy at hospital discharge. 3

4 Stroke Measures 4 and 5 Stroke Measure Stroke 4 NQF 0437 Stroke 5 NQF 0438 Details Title Ischemic stroke thrombotic therapy for patients arriving within two hours of symptom onset Description Acute Ischemic stroke patients who arrive at this hospital within two hours of the last known time and for whom IV t-pa was initiated at this hospital within three hours of the last known time. Title Ischemic antithrombotic therapy by day two Description Ischemic stroke patients administered antithrombotic therapy by the end of hospital day two. 4

5 Stroke Measure 6 Stroke Measure Stroke 6 NQF 0439 Details Title Ischemic stroke discharge on statins Description Ischemic stroke patients with LDL greater than or equal to 100mg/dL or LDL not measured or who were on a lipid lowering medication prior to hospital arrival are prescribed statin medication at discharge. 5

6 Stroke Measure 7 Stroke Measure Stroke 8 NQF 0440 Details Title Ischemic or hemorrhagic stroke stroke education Description Ischemic or hemorrhagic stroke patients or their caregivers who were given education materials during the hospital stay addressing all of the following: Activation of emergency medical system Need for follow-up after discharge Medications prescribed at discharge Risk factors for stroke, warning signs, and symptoms of stroke 6

7 Stroke Measure 10 Stroke Measure Stroke 10 NQF 0441 Details Title Ischemic or hemorrhagic stroke rehabilitation assessment Description Ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services 7

8 VTE Measure 1 VTE Measure VTE 1 NQF 0371 Details Title VTE Prophylaxis within 24 hours of arrival (including surgeries) Description This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or day after hospital admission. 8

9 VTE Measure 2 VTE Measure VTE 2 NQF 0372 Details Title Intensive Care Unit VTE prophylaxis given (include why not if applicable) Description This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after the initial admission or transfer to the Intensive Care Unit or surgery end date for surgeries that start the day of or day after the Intensive Care Unit. 9

10 VTE Measure 3 VTE Measure VTE 3 NQF 0373 Details Title Anticoagulation overlap therapy Description This measure assesses the number of patients diagnosed with confirmed VTE who received an overlap of parenteral intravenous or subcutaneous anticoagulation and warfarin therapy. For patients who received less than five days of overlap therapy they must be discharged on both medications. Overlap therapy must be administered for at least five days with an international normalized ratio greater than or equal to two prior to discontinuation of the parenteral anticoagulation therapy or the patient must be discharged on both medications. 10

11 VTE Measure 4 VTE Measure VTE 4 NQF 0374 Details Title Platelet monitoring on unfractionated heparin Description This measure assesses the number of patients diagnosed with confirmed VTE who received intravenous unfractionated heparin therapy dosages and had their platelet counts monitored using defined parameters such as a nomogram or protocol. 11

12 VTE Measure 5 VTE Measure VTE 5 NQF 0375 Details Title VTE discharge instructions Description This measure assesses the number of patients diagnosed with confirmed VTE that are discharged to home, to home with home health, or home hospice on warfarin with written discharge instructions that address all four criteria: Compliance issues Dietary advice Follow-up monitoring Information about the potential for adverse drug reactions/interactions. 12

13 VTE Measure 6 VTE Measure VTE 6 NQF 0376 Details Title Incidence of potentially preventable VTE Description This measure assesses the number of patients diagnosed with confirmed VTE during hospitalization (not present on arrival) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date. 13

14 Meeting Meaningful Use Challenging if physicians not yet live on electronic documentation and order entry Suggested workflow involves use of Problem List RXM Provider Order Management Provider Documentation How do you accomplish meeting Stage 1 when all the pieces of the puzzle are not in place? 14

15 Fields for Reporting for Stroke Data gathered from Admissions Patient Type Admission Date Discharge Date Abstracting Principal diagnosis codes Patient s Problem List Active problem of Ischemic Stroke Managed in Summary Panel in the EMR Ischemic Stroke Problem set to active and SNOMED field filled in Drugs must be loaded and drug strings created RXNorm file must be loaded 15

16 Fields for Exclusion for Stroke Admissions B/AR Less than 18 years old (Date of Birth) Length of stay greater than 120 days (captured from admit/discharge dates) Discharge disposition D/C or transfer to another hospital for inpatient care Left AMA or discontinued care Expired D/C or transfer to a federal healthcare facility D/C or transfer to hospice Admitted for elective Carotid Intervention Assessments Contraindication for prescribing anti-thrombotic Comfort Measures patients Clinical Trials patients 16

17 Medical Problem List Dictionary 17

18 Stroke Admission Use Nursing documentation to accomplish Stage 1 Assessments MAR Order Entry 18

19 Value Sets Joint Commission Value Sets are used to pull data from documentation which can be sent to CMS for reporting purposes. 19

20 Stroke Measure 4 The reporting algorithm will look to the documented dated and time of onset of symptoms and then compare this to the date and time of IV t-pa administration on the MAR along with the RxNorm code associated to the IV t-pa to determine If the patient arrived within 2 hours of symptom onset If t-pa was administered within 3 hours 20

21 Stroke Measure 4 Exclusion If IV Thrombolytic therapy was contraindicated, a reason must be documented. Accomplished by using this group response: 21

22 Stroke Measure 5 The reporting algorithm will look to the date and time the medication was documented as administered (MAR) to determine if it was given by the end of hospital day 2 Anti-thrombotic therapy contraindications captured in the query described for Measure 4 22

23 Stroke Measure 10 23

24 Stroke Discharge 24

25 Stroke Measure 2 All possible Anti-thrombotic medications listed in a group response with Value Set codes assigned to the elemental code of each medication Set up contraindications the same way if the patient was not prescribed or continued on anti-thrombotic at discharge. 25

26 Stroke Measure 3 Similar set up as measure 2 26

27 Stroke Measure 6 Similar set up as measure 2 27

28 Measure 6 Lab setup Load LOINC codes on LDL tab Enter Value Set code under Default LOINC (Lab Test dictionary, Page 6) 28

29 Stroke Measure 8 29

30 Fields for Reporting VTE Admissions Patient type Inpatient Admission date Surgery end date Discharge date Problem List 30

31 Fields for VTE Exclusions Admissions Age less than 18 years old Length of stay >120 days Assessments Comfort Measures only Clinical Trial enrollment Problem List Principal diagnosis code of Mental Disorders Hemorrhagic or Ischemic Stroke Obstetrics VTE 31

32 VTE Admission 32

33 VTE Measure 1 33

34 VTE Measure 2 34

35 Measures 1 and 2 Reporting algorithm looks to Rx Norm code associated to the medication (Drug Dictionary) Medication administration documentation (MAR) Contraindications Documented on Assessment if medication not administered 35

36 VTE Measure 6 36

37 VTE Discharge 37

38 VTE Measure 3 Warfarin and parenteral anticoagulant administration over 5 days (MAR and RXNorm Codes) INR 2.0 or greater prior to discontinuation of parenteral anticoagulation therapy (Lab) Discharged on both Warfarin and Overlap Therapy if < 5 days of Overlap therapy and INR < 2.0 (Assessment) 38

39 Measure 3 39

40 VTE Measure 4 MAR assessment attached to appropriate drug(s) MAR administration dates indicate medication was administered based on protocol Platelet Count test time and result indicate compliance 40

41 VTE Measure 5 41

42 Summary Determine what workflow will work best for your facility Decide who will do the documentation Determine method for prompting Physicians to document needed information Make sure LOINC and RxNorm information has been loaded Decide exactly what responses will be used for your facility and enter the corresponding Value Set Codes for the Elemental Codes in your Group Response Dictionary Develop reports needed to extract the Meaningful Use data and test thoroughly to make sure the correct data is being pulled 42

43 MEDITECH Resource Link 43

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