Quality Measures Setup Stages 1 and 2

Quality Measures Setup
Stages 1 and 2 - 2014 Criteria
Eligible Hospitals
This handout is being provided as a supplemental guide for setup throughout the CPSI
System to prepare for Quality Measures. It is not a comprehensive list of all of the data
elements used to calculate CQM’s, but just the ones each facility will need to setup and
maintain.
Per the National Library of Medicine UMLS License Agreement, CPSI cannot distribute lists
of codes contained in each value set. We can provide guidance and links to the
resources necessary to look up the codes. Please contact CPSI support for help with this
process.
Discharge Codes
Add SNOMED codes from the following value sets to the facility’s discharge codes that
are used for any of the purposes listed. (NQF 338, 373, 374, 375, 435, 436, 439, 440 & 441)
•
Discharge to Another Hospital (OID 2.16.840.1.113883.3.117.1.7.1.87)
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Left Against Medical Advice (OID 2.16.840.1.113883.3.117.1.7.1.308)
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Discharged to Home for Hospice Care (OID 2.16.840.1.113883.3.117.1.7.1.209)
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Patient Expired (OID 2.16.840.1.113883.3.117.1.7.1.309)
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Discharge to Healthcare Facility for Hospice Care (OID
2.16.840.1.113883.3.117.1.7.1.207)
•
Discharge to Home or Police Custody (OID 2.16.840.1.113883.3.117.1.7.1.82)
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Discharged to Rehabilitation Facility (OID 2.16.840.1.113883.3.117.1.7.1.132)
Room Types
Set up all ICU rooms with Room Type I in Table Maintenance. (NQF 371 & 372)
Flow Charts/E-Forms
General:
•
Add “Inpatient Arrival” question to Initial Interviews for Inpatient Units.
•
Important Note: This question should only be answered for true inpatients, not
observation patients. Giving the question a description to help clarify is suggested.
•
Add “Education Refusal” Widget to Discharge Summary & Instruction Flow Charts/EForms.
•
Add “Comfort Measures Only” Widget to daily Flow Charts/E-Forms.
Revision Date: 3/3/2014
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Quality Measures Setup
Stages 1 and 2 - 2014 Criteria
Eligible Hospitals
Stroke Measures:
•
Add “Stroke Admit” Widget to Flow Charts and E-Forms used for patients presenting
with stroke symptoms.
•
Add “Stroke Discharge” Widget to DC Summary & Instruction Flow Charts and EForms.
VTE Measures:
•
Add “VTE Prophylaxis” Widget to Flow Charts and E-Forms used for VTE risk
screening/protocol for inpatients.
•
Add “VTE Treatment” Widget to daily Flow Charts/E-Forms.
Patient Education Documents
Home Management Plan of Care – Children’s Asthma Care (NQF 338):
•
Create custom Patient Education Document for pediatric asthma Home
Management Plan of Care. (Examples at
http://www.health.state.mn.us/asthma/AAP-nonpro.html.)
•
Add LOINC code to document from Asthma Management Plan value set. (OID
2.16.840.1.113883.3.117.1.7.1.131)
Stroke Education (NQF 440):
•
Create custom Patient Education Document for Stroke Education.
•
Review NQF 440 for guidance on what specific elements must be addressed in this
document.
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Add SNOMED code to document from Activation of Emergency Medical System
Education value set. (OID 2.16.840.1.113883.3.117.1.7.1.377)
•
Add SNOMED code to document from Instructions for Follow Up After Discharge
value set. (OID 2.16.840.1.113883.3.117.1.7.1.378)
•
Add SNOMED code to document from Prescribed Medications Education value set.
(OID 2.16.840.1.113883.3.117.1.7.1.379)
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Add SNOMED code to document from Risk Factors Education value set.
(OID 2.16.840.1.113883.3.117.1.7.1.380)
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Add SNOMED code to document from Warning Signs and Symptoms Education
value set. (OID 2.16.840.1.113883.3.117.1.7.1.381)
Revision Date: 3/3/2014
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Quality Measures Setup
Stages 1 and 2 - 2014 Criteria
Eligible Hospitals
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Add SNOMED code to document from Written Information Given value set.
(OID 2.16.840.1.113883.3.117.1.7.1.415)
VTE Discharge Education (NQF 375):
•
Create custom Patient Education Document for VTE Discharge Education.
•
Review NQF 375 for guidance on what specific elements must be addressed in this
document.
•
Add SNOMED code to document from Adverse Drug Reactions Education value set.
(OID 2.16.840.1.113883.3.117.1.7.1.304)
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Add SNOMED code to document from Instructions for Drug Interactions Education
value set. (OID 2.16.840.1.113883.3.117.1.7.1.414)
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Add SNOMED code to document from INR Monitoring Education value set.
(OID 2.16.840.1.113883.3.117.1.7.1.416)
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Add SNOMED code to document from Medication Compliance Education value set.
(OID 2.16.840.1.113883.3.117.1.7.1.301)
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Add SNOMED code to document from Vitamin K Dietary Management value set.
(OID 2.16.840.1.113883.3.117.1.7.1.302)
•
Add SNOMED code to document from Recommendation not to change diet value
set. (OID 2.16.840.1.113883.3.117.1.7.1.413)
•
Add SNOMED code to document from Follow-Up Monitoring value set.
(OID 2.16.840.1.113883.3.117.1.7.1.303)
•
Add SNOMED code to document from Written Information Given value set.
(OID 2.16.840.1.113883.3.117.1.7.1.415)
Ancillary Order Items
The lab department should already be in the process of attaching LOINC Codes to
reference range tables for all lab items for Stage 2 MU. For Quality Measures, confirm
that reference ranges for the following items are set up with appropriate LOINC Codes.
•
LDL-c (NQF 439, OID 2.16.840.1.113883.3.117.1.7.1.215)
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INR (NQF 371 & 372) OID 2.16.840.1.113883.3.117.1.7.1.213)
•
Platelet Count (NQF 374, OID 2.16.840.1.113883.3.117.1.7.1.267)
Revision Date: 3/3/2014
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Quality Measures Setup
Stages 1 and 2 - 2014 Criteria
Eligible Hospitals
Attach LOINC codes from the following value set to all radiology order items that would
be used to confirm VTE diagnoses (NQF 374):
•
VTE Diagnostic Test (OID 2.16.840.1.113883.3.117.1.7.1.276)
Attach SNOMED codes from the following value set to order items that would be used to
order a rehab assessment for stroke patients (NQF 441):
•
Rehabilitation Services (OID 2.16.840.1.113883.3.117.1.7.1.221)
Charge Items
Attach SNOMED codes from the following value set to all items that would be charged to
the patient’s account for anesthesia. This could be done by attaching one code to a
specific anesthesia item or by attaching one of the codes to each procedure that
involves anesthesia, depending on the hospital policies. (NQF 371 & 372)
•
General or Neuraxial Anesthesia (OID 2.16.840.1.113883.3.117.1.7.1.254)
Attach SNOMED codes from any of the following value sets to items that will be used to
charge for the use of Mechanical VTE Prophylaxis. If the use of these devices is included
in the room charge at the facility, consider setting up a zero-charge item to be reflexed
when nursing documents that they have applied the device. (NQF 371 & 372)
•
Graduated compression stockings (OID 2.16.840.1.113883.3.117.1.7.1.256)
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Intermittent pneumatic compression devices (OID 2.16.840.1.113883.3.117.1.7.1.214)
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Venous foot pumps (OID 2.16.840.1.113883.3.117.1.7.1.230)
Medication Routes
Attach SNOMED codes from the following value sets to all medication routes used for
subcutaneous or intravenous administrations in the Pharmacy Route Table. (NQF 371,
372, 374, & 376)
•
Subcutaneous Route (OID 2.16.840.1.113883.3.117.1.7.1.223)
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Intravenous Route (OID 2.16.840.1.113883.3.117.1.7.1.222)
Revision Date: 3/3/2014
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Quality Measures Setup
Stages 1 and 2 - 2014 Criteria
Eligible Hospitals
Medication Omit Reasons
Attach SNOMED codes from the following value set to all medication omit reasons used
on the eMAR to indicate that a patient has refused a medication in the Omit Reasons
Table. (NQF 371, 372, 373, 376, 437, & 438)
•
Patient Refusal (OID 2.16.840.1.113883.3.117.1.7.1.93)
Attestation Disclaimer:
Meaningful Use attestation confirms the use of a certified Electronic Health Record (EHR)
to regulatory standards over a specified period of time. CPSI and TruBridge Meaningful
Use certified products, recommended processes and supporting documentation are
based on CPSI’s interpretation of the Meaningful Use regulations, technical specifications
and vendor specifications provided by CMS, ONC and NIST. Each client is solely
responsible for its attestation being a complete and accurate reflection of its EHR use
during the attestation period and that any records needed to defend the attestation in
an audit are maintained. With the exception of vendor documentation that may be
required in support of a client’s attestation, CPSI and TruBridge bear no responsibility for
attestation information submitted by the client.
Revision Date: 3/3/2014
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