Meaningful Use Requirement

Transcription

1 Meaningful Use Requirement -Both CMS and Meaningful Use require our organization to submit electronic reports that show our VTE Quality Measures(QM) compliance -Medical Center Navicent Health(MCNH) will be reporting data collected from Cerner for VTE Measures 1, 2, and 6. VTE 1-VTE Prophylaxis All inpatients should receive Mechanical and/or Pharmacological VTE prophylaxis (unless contraindicated): On the day of or the day after hospital admission On the day of or the day after surgery end date for surgeries that start the day of or the day after hospital admission. VTE 2-ICU VTE Prophylaxis All ICU inpatients should receive Mechanical or Pharmacological VTE prophylaxis (unless contraindicated): On the day of, or the day after ICU admission or transfer On the day of, or the day after surgery end date for surgeries that start the day of or the day after ICU admission (or transfer) VTE 6-Incidence of Potentially- Preventable VTE This measure looks at those inpatients with a confirmed VTE diagnosis during hospitalization. It counts only those that did not receive any prophylaxis prior to the VTE diagnostic test order date.

2 Ordering and Documentation Requirements by Provider: All adult inpatients should receive Mechanical and/or Pharmacological VTE prophylaxis, unless it is contraindicated. If contraindicated, there must be a reason documented by a provider, (MD, PA, NP, APN) Any of these orders can be found as individual orders or in the DVT/VTE Prophylaxis Subphase. Admission PowerPlans contain the DVT Prophylaxis Subphase. (Figure A) o The sub phase includes orders for mechanical and pharmacological prophylaxis and also reason contraindicated documentation options. (Figure B) Figure A: locating the DVT/VTE Prophylaxis Subphase- The DVT/VTE Prophylaxis Subphase is embedded as part of most PowerPlan especially admission. It can also be entered as an individual PowerPlan. It contains orders for mechanical VTE prophylaxis as well as pharmacological. Common associated labs can also be entered from the DVT/VTE prophylaxis Subphase.

3 Figure B: Reason Prophylaxis Not Received Contraindication orders located in the DVT/VTE Subphase Reason VTE Prophylaxis Not Received must be selected and documented in the orders if there is no prophylaxis ordered for the patient. Select the Reason order. Complete the powerform that pops up. Sign it with the green check mark to the upper left. The Form below will display for the provider to answer when the PowerPlan is initiated for signature. First choose a reason. If Medical Reason answer box to the right. If Patient Refused answer box at the bottom.

4 Tracking completion of eqm goals in the Quality Measures Mpage: When the Subphase has been entered, the VTE quality measures order activated the Quality Measures Mpage. This screen can be located from the chart menu by clicking Quality Measures Mpage (Figure C) As the measures are documented, the user can view the items that are complete and incomplete on the Mpage. This page is interactive and will allow the user to enter orders, and documentation from this page by clicking on any corresponding blue links. (Figure D) Figure C: Quality Measures Mpage Figure D: Interactive Sections of Quality Measures Mpage The Prophylaxis section tracks orders and documentation from the chart for prophylaxis ordered and administered. It also tracks any contraindication that has been documented. Each section has interactive blue links to use when placing orders and/or document in the appropriate areas of the chart. Section for Confirmed VTE- (see more below in Figure E)

5 Figure D: Continued Other Therapies and Treatments including Discharge Information are included in the Mpage for tracking, along with links for ordering and documentation.

6 Figure E: Documenting a Confirmed VTE. When a DVT/VTE is suspected, and a provider has placed an appropriate diagnostic order the Mpage will display the date and time an order was placed. The page will also display a document link so the provider can update the page with the results. When documenting the results of VTE diagnostic testing, click the document link to display the form for results selection. Then sign by clicking the green check mark in the upper left corner. The confirmation must be documented by physician, APN, or PA. (Confirmed VTE can also be documented by using the Diagnosis Tool in Problems and Diagnosis -see figure F below.) Figure F: Problems and Diagnosis -For Documentation of Confirmed VTE Problems and Diagnosis can be located in the chart menu. Problems and Diagnosis can also be located from the PowerNotes and will pull diagnosis into your notes.

7 Add Diagnosis screen allows the provider to enter a diagnosis and then drill down to specified ICD-10. Click the Add button in Diagnosis and type the diagnosis in the search window and click the binoculars. Select one the diagnosis from the search list, then click OK on the search screen and the Add screen. Once the non-specific or unspecified diagnosis has been added, the diagnosis tool will assist you to narrow it down to approved specified by answer a few questions. This is true will all diagnosis you can enter, not just VTE. Access the Diagnosis Assistant by clicking the yellow bulls-eye icon with the arrow on the diagnosis screen.

8 Answering the Anatomy Questions will specify and narrow the list of possibilities usually down to ONE. Example of diagnosis choices before you answer assistant questions: Example of diagnosis choices after you answer assistant questions: NOTE: If you had typed this wording into the search field for diagnosis, the system will typically match it to a specified code and the bulls-eye would have been completed and grayed out. To signify that you already had entered a specified ICD-10. The Assistant is only there for when you need it. The Problem and Diagnosis Screen can also be opened from your PowerNote. This will also pull the codified diagnosis into your Note.

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