Strategic – Proactive Review and Setup
VTE/StrokeMeaningful Use Clinical Rules
2014 Guidelines
Review of UMLS (2014 requirements)◦ And formerly HITSP
Clinical Quality Measures review Value Set review Evaluate site specific criteria to implement 5 clinical
decision support “interventions”◦ MU Stage II requirement
End with clear understanding and mini-toolset to initiate/finalize site specific conversations regarding these MU Stage II requirements
Note: the Client Server 5.66 platform was utilized for the basis of this presentation
What to expect from this webinar
WILL NOT review global Meaningful Use items
WILL NOT interpret ARRA/CMS code WILL NOT provide actual Plug-N-Play rules
for production◦ Due to the nature and complexity of these rules,
future Webinars will cover actual build and rollout
Advanced Rules - VTE-Stroke Deployment
What not to expect…
Healthcare Information Technology Standards Panel (HITSP)
Unified Medical Language System (UMLS)◦ RxNorm◦ LOINC◦ SNOMED◦ ICD-9◦ ICD-10
“..The value sets contain all the data elements previously found in HITSP TN906 v1.1 specifications. Upon reviewing the value sets, it will be clear that the reliance on codified data has increased exponentially. National and international standards are becoming a necessity for exchanging data for interoperability and for quality reporting. “
HITSP vs. UMLS
MEDITECH's Best Practice documents contain workflow methods which have been vetted through numerous clinical and customer representatives. The corresponding SQL reports have been created with precise alignment to the workflow methods found within the Best Practice documents in conformance with the 2014 specifications. 1
Best Practices and Data Capture
“Use clinical decision support to improve performance on high-priority health conditions”
[For Stage II]…Implement 5 clinical decision support interventions related to 4 or more clinical quality measures, if applicable, at a relevant point in patient care for the entire EHR reporting period.
2014 MU Clinical Decision Support
CMS eMeasure ID NQF # Measure Title Measure Description
104 0435 Stroke-2 Ischemic stroke – Discharged on anti-thrombotic therapy.
Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge.
71 0436 Stroke-3 Ischemic stroke – Anticoagulation Therapy for Atrial Fibrillation/Flutter
Ischemic stroke patients with atrial fibrillation/flutter who are prescribed anticoagulation therapy at hospital discharge.
91 0437 Stroke-4 Ischemic stroke – Thrombolytic Therapy
Acute ischemic stroke patients who arrive at this hospital within 2 hours (120 minutes) of time last known well and for whom IV t-PA was initiated at this hospital within 3 hours (180 minutes) of time last known well.
72 0438 Stroke-5 Ischemic stroke – Antithrombotic therapy by end of hospital day two
Ischemic stroke patients administered antithrombotic therapy by the end of hospital day two.
105 0439 Stroke-6 Ischemic stroke – Discharged on Statin Medication
Ischemic stroke patients with LDL greater than or equal to 100 mg/dL, or LDL not measured, or, who were on a lipid- lowering medication prior to hospital arrival are prescribed statin medication at hospital discharge.
Stroke CQM Finalized for 2014
CMS eMeasure ID NQF # Measure Title Measure Description
107 0440 Stroke-8 Ischemic or hemorrhagic stroke – Stroke education
Ischemic or hemorrhagic stroke patients or their caregivers who were given educational 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, and warning signs and symptoms of stroke.
102 0441 Stroke-10 Ischemic or hemorrhagic stroke – Assessed for Rehabilitation
Ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services.
Stroke CQM Finalized for 2014
Stroke-2 (ischemic)◦ Discharged on Antithrombotic Therapy
Stroke-3 (ischemic)◦ Discharged on Anticoagulation Therapy◦ Atrial Fibrillation/Flutter
Stroke-4 (ischemic)◦ Thrombotic Therapy – 2 hr arrival/3 hr IV t-PA
Stroke-5 (ischemic)◦ Antithrombotic therapy by end of hospital day 2
Stroke-6 (ischemic)◦ Discharged on Statin Medication (LDL>100 or prior use)
Stroke-8 (ischemic/hemorrhagic)◦ Stroke Education
Stroke-10 (ischemic/hemorrhagic)◦ Assessed for Rehabilitation
Stroke CQM - summary
You are not required to use all items in a value set in your system. You can choose to use only those which most closely match your workflow and patient needs. However, any items you do include must be mapped to the standard nomenclature. For example, when creating a group response for contraindications for ordering a medication, all of the reasons in the value set do not have to be included. The elements in the group response must all come from the value set and must all be mapped to the nomenclature specified in the value set.1 1 Data Capture for Stroke/VTE Measures, MEDITECH CS Best Practice Documentation
A word about Value Sets…
Medication, Discharge: Anticoagulant Therapy using Anticoagulant Therapy RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.200)
Medication, Order: Thrombolytic (t-PA) Therapy using Thrombolytic (t-PA) Therapy RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.226)
Medication, Administered: Antithrombotic Therapy using Antithrombotic Therapy RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.201).
Medication, Discharge: Statin using Statin RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.225).
Stroke Value Sets - Pharmacologic
The following value sets are used for stroke diagnosis: ◦ Diagnosis, Active: Hemorrhagic Stroke using
Hemorrhagic Stroke Grouping value set (2.16.840.1.113883.3.117.1.7.1.212).
◦ Diagnosis, Active: Ischemic Stroke using Ischemic Stroke Grouping value set (2.16.840.1.113883.3.117.1.7.1.247).
Stroke Value Sets - Diagnosis
Value set for the LDL test: ◦ Laboratory Test, Result: LDL-c using LDL-c LOINC
Value Set (2.16.840.1.113883.3.117.1.7.1.215). Value sets for Palliative Care:
◦ Intervention, Order: Palliative Care using Palliative Care SNOMED CT Value Set:(2.16.840.1.113883.3.526.2.1076).
◦ Intervention, Performed: Palliative Care using Palliative Care SNOMED CT Value Set: (2.16.840.1.113883.3.526.2.1076).
Stroke Value Sets – LAB, Comfort
CMS eMeasure ID NQF # Measure Title Measure Description
108 0371 Venous Thromboembolism (VTE)-1 VTE prophylaxis
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 the day after hospital admission.
190 0372 VTE-2 Intensive Care Unit (ICU) VTE prophylaxis
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 ICU or surgery end date for surgeries that start the day of or the day after ICU admission (or transfer).
VTE CQM Finalized for 2014
CMS eMeasure ID NQF # Measure Title Measure Description
73 0373 VTE-3 VTE Patients with Anticoagulation Overlap Therapy
This measure assesses the number of patients diagnosed with confirmed VTE who received an overlap of parenteral (intravenous [IV] or subcutaneous [subcu]) anticoagulation and warfarin therapy. For patients who received less than five days of overlap therapy, they must be discharged on both medications or have a reason for discontinuation of overlap therapy. Overlap therapy must be administered for at least five days with an international normalized ratio (INR) greater than or equal to 2 prior to discontinuation of the parenteral anticoagulation therapy, discharged on both medications or have a reason for discontinuation of overlap therapy.
109 0374
VTE-4 VTE Patients Receiving Unfractionated Heparin (UFH) with Dosages/Platelet Count Monitoring by Protocol (or Nomogram)
This measure assesses the number of patients diagnosed with confirmed VTE who received intravenous (IV) UFH therapy dosages AND had their platelet counts monitored using defined parameters such as a nomogram or protocol.
VTE CQM Finalized for 2014
CMS eMeasure ID NQF # Measure Title Measure Description
110 0375 VTE-5 VTE discharge instructions
This measure assesses the number of patients diagnosed with confirmed VTE that are discharged to home, home care, court/law enforcement or home on hospice care on warfarin with written discharge instructions that address all four criteria: compliance issues, dietary advice, follow-up monitoring, and information about the potential for adverse drug reactions/interactions.
114 0376 VTE-6 Incidence of potentially preventable VTE
This measure assesses the number of patients diagnosed with confirmed VTE during hospitalization (not present at admission) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date.
VTE CQM Finalized for 2014
VTE-1◦ VTE Prophylaxis
VTE-2◦ ICU VTE Prophylaxis
VTE-3 (confirmed VTE)◦ Anticoagulation Overlap Therapy (IV/SQ and Warfarin) for 5
days (INR>2) VTE-4 (confirmed VTE)
◦ Unfractionated Heparin AND monitored platelets VTE-5 (confirmed VTE)
◦ Discharge Instructions VTE-6 (confirmed VTE during stay)
◦ Not present at admission and did not receive VTE prophylaxis
VTE CQM - summary
Value sets for Pharmacologic Prophylaxis: ◦ Medication, Administered: Direct Thrombin Inhibitor using Direct Thrombin Inhibitor RxNorm
Value Set (2.16.840.1.113883.3.117.1.7.1.205). ◦ Medication, Administered: Injectable Factor Xa Inhibitor using Injectable Factor Xa Inhibitor
RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.211). ◦ Medication, Administered: Low Molecular Weight Heparin using Low Molecular Weight Heparin
RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.219). ◦ Medication, Administered: Oral Factor Xa Inhibitor using Oral Factor Xa Inhibitor RxNorm Value
Set (2.16.840.1.113883.3.117.1.7.1.134). ◦ Medication, Administered: Unfractionated Heparin using Unfractionated Heparin RxNorm Value
Set (2.16.840.1.113883.3.117.1.7.1.218). ◦ Medication, Order: Parenteral Anticoagulant using Parenteral Anticoagulant RxNorm Value
Set (2.16.840.1.113883.3.117.1.7.1.266). ◦ Medication, Administered: Warfarin using Warfarin RxNorm Value Set
(2.16.840.1.113883.3.117.1.7.1.232). If unfractionated heparin is used, the following value sets regarding Route of
Administration will be checked: ◦ Attribute: Route: Subcutaneous route using Subcutaneous route SNOMED-CT Value Set
(2.16.840.1.113883.3.117.1.7.1.223). ◦ Attribute: Route: Intravenous route using Intravenous route SNOMED-CT Value Set
(2.16.840.1.113883.3.117.1.7.1.222).
VTE Value Sets - Pharmacologic
Value Set for INR Procedure:◦ Laboratory Test, Result: INR using INR LOINC Value
Set (2.16.840.1.113883.3.117.1.7.1.213). Value sets for Palliative Care:
◦ Intervention, Order: Palliative Care using Palliative Care SNOMED CT Value Set:(2.16.840.1.113883.3.526.2.1076).
◦ Intervention, Performed: Palliative Care using Palliative Care SNOMED CT Value Set: (2.16.840.1.113883.3.526.2.1076).
VTE Value Sets – LAB, Comfort
The VTE measures use the following value set from VSAC to determine VTE population: ◦ Diagnosis, Active: Venous Thromboembolism using Venous
Thromboembolism Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.279). ◦ Diagnosis, Active: Atrial Fibrillation/Flutter using Atrial Fibrillation/Flutter
Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.202). The following value sets are used to exclude patients:
◦ Diagnosis, Active: Obstetrics VTE using Obstetrics VTE Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.264).
◦ Diagnosis, Active: Obstetrics using Obstetrics Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.263).
◦ Diagnosis, Active: Hemorrhagic Stroke using Hemorrhagic Stroke Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.212).
◦ Diagnosis, Active: Ischemic Stroke using Ischemic Stroke Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.247).
◦ Diagnosis, Active: Mental Disorders using Mental Disorders Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.262).
VTE Value Sets - Diagnosis
Value set for Diagnostic Test:◦ Diagnostic Study, Result: VTE Diagnostic Test
using VTE Diagnostic Test Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.276).
Value Set for confirmed VTE:◦ Attribute: Result: VTE Confirmed using VTE
Confirmed SNOMED CT Value Set (2.16.840.1.113883.3.117.1.7.1.407).
VTE Value Set - Diagnostic
Patient age Resuscitation status Problem List Provider – yes/no Diagnosis vs. Problem List Drug Type (AHFS Classification)
◦ Inpatient “active” medication orders◦ Ambulatory “active” medication orders
“Confirmed VTE”◦ Procedure Status vs. SNOMED CT Value Set content
Monitored LAB values
Rule Logic content
Challenges
Site Specific Workflow◦ Patient Assessments (VTE/Stroke)
Performed when and by whom◦ Dictionary Specific Build
Standardization for multi-site facilities◦ Provider/Physician Expectations
Required at Order Entry? Admission criteria
◦ Inclusion/Exclusion (e.g. ICU direct admit)
Challenges
Medication Identification – PHA Drug Formulary
Challenges
Drug Type
Customer Defined Parameter
Medication Identification – PHA Drug Formulary◦ Value Set differences (HITSP/VSAC)
Stroke has Warfarin, VTE DOES NOT!
Challenges
Medication Identification – RXM Drug
Challenges
Drug Type
“Provider” Identification◦ MIS User Dictionary
Profile This User is Provider
Challenges
“Diagnosis” Identification◦ Typically done post discharge in ABS by Coders◦ Problem List◦ New Keywords for rules (Magic and CS)
[f pt prob current]
Challenges
“Confirmed” VTE◦ What determines a “complete”/”reported” exam
and/or procedure At what point does the Status change
◦ Role based, multi-collaborative process
Challenges
Where Rules are attachedRemember …relevant point in patient care…◦ POM Enabled◦ OE/OM Categories
MED LAB MIC RAD
◦ PHA/POM Enabled Rules “Global” in PHA Customer Defined Parameters
◦ Less Popular - Underutilized PHA Refill Rules LAB Verify Rules
Challenges
Examples
Description ◦ Ischemic stroke patients prescribed
antithrombotic therapy at hospital discharge. Initial Patient Population
◦ Patients admitted to the hospital for inpatient acute care with a principal diagnosis code for ischemic or hemorrhagic stroke with hospital stays <= 120 days during the measurement period for patients age 18 and older at the time of hospital admission.
Example – Stroke-2 (NQF 0435)
NQF 0435 Measure captures patients who are prescribed antithrombotic therapy at discharge. ◦ In the 2011 specifications, HITSP provided a SNOMED
code to use to document the provider’s intention to send the patient home on a specific discharge medication. This SNOMED was INT and was used in a query on an order in POM. This allowed an alternate workflow to documenting discharge medications in discharge. However, this SNOMED code is not included in the 2014 specifications. Therefore, no alternate workflow is possible. All discharge medications must be documented through the Discharge routine.
Example – Stroke-2 (NQF 0435)
Rule Logic must contain◦ Ischemic Stroke “diagnosis”◦ NOT Comfort Care (resuscitation order)◦ Patient age > 18◦ Length of Stay < 120 days◦ Antithrombotic therapy at discharge
Home Meds/Discharged Meds
Example – Stroke-2 (NQF 0435)
POM Display/Output (simple)
POM Display/Output (required)
Description◦ This measure assesses the number of patients diagnosed with
confirmed VTE who received overlaps of parenteral (intravenous [IV] or subcutaneous [subcu]) anticoagulation and warfarin therapies. Patients who received fewer than five days of overlap therapy should be discharged on both medications or have a reason for discontinuation of overlap therapy. Overlap therapy should be administered for at least five days with an international normalized ratio (INR) greater than or equal to two prior to discontinuation of the parenteral anticoagulation therapy, discharged on both medications, or have a reason for discontinuation of overlap therapy.
Initial Patient Population ◦ Patients with a diagnosis code for venous thromboembolism (VTE),
a patient age greater than or equal to 18 years, and a length of stay less than or equal to 120 days.
Example – VTE-3 (NQF 0373)
NQF 0373 Measure captures patients who are prescribed antithrombotic therapy at discharge. ◦ In the 2011 specifications, HITSP provided a SNOMED
code to use to document the provider’s intention to send the patient home on a specified discharge medication. This SNOMED was INT 40 and was used in a query on an order in POM. This allowed an alternate workflow to documenting discharge medications in discharge. However, this SNOMED code is not included in the 2014 specifications. Therefore, no alternate workflow is possible. All discharge medications must be documented through the Discharge routine.
Example – VTE-3 (NQF 0373)
Rule Logic must contain◦ Confirmed VTE◦ NOT Comfort Care (resuscitation order)◦ Patient age > 18◦ Length of Stay < 120 days◦ 5+ days with INR > 2◦ Inpatient IV Anticoagulant Therapy◦ Inpatient PO Anticoagulant Therapy◦ Ambulatory PO Anticoagulant Therapy
Example – VTE-3 (NQF 0373)
VTE-3 POM Display (inpatient)
VTE-3 POM Display (discharged)
VTE-3 -– 6x OM Conflict Display
PHA Alternate DisplaysStroke 2
VTE 3
Potential MEDITECH Functionality Additions◦ Rule Evaluation
At “Open Chart” via EMR◦ Discharge Functionality
Multi-collaborative DON’T GET US STARTED!
Stage 3 Recommendations◦ “…Implement 15 clinical decision support interventions or
guidance related to five or more clinical quality measures that are presented at a relevant point in patient care for the entire EHR reporting period…”2
2 SGRP113: Clinical Decision Support, Draft Recommendations Meaningful Use Stage 3, Paul Tang et al
What does the Future Hold
Kevin McConnell, PharmD, PHD.Co-founder and Executive VP of Service Delivery
Kevin has 24 years of relevant professional experience including over 13 years’ experience as a MEDITECH consultant, project manager, and application specialist in healthcare system implementation and assessments. Specializing in the implementation and support of MEDITECH’s Advanced Clinical Applications and related applications and interfaces. Areas of expertise include Meaningful Use assessments and planning, pre and post implementation assessments, developing implementation and training plans, revenue cycle, coordinating process and departmental workflow enhancement/redesign, facilitating/managing application implementation teams, training end-users and change management. Past positions include, but are not limited too, Director of Pharmacy, Clinical Pharmacist, Staff Pharmacist, Instructor at a College of Pharmacy, and owner of a retail/community pharmacy.
Kevin is a frequent Presenter at the Annual MUSE International Conferences including topics such as Writing Clinical Rule and PHA/NPR for Dummies.
Thank You…