[MT-L] CS 5.65 How are other facilities accommodating the CMS requirements for an ER Transition record?
Wood, Carrie L
Hello,
We are a Client Server 5.65 facility live with EDM. Recently it has been requested for CMS purposes that the discharged ER patient receive a list of procedures, labs, scans, x-rays that were performed upon them on this current visit. When the discharge instructions in EDM print a Patient Visit Information page prints with the other elements that are needed. We would like to know how other facilities are accommodating this list and if there is any way to add this to the Patient Visit Information Page that prints with the departure packet?
I realize that their is a CCD or Patient Health Record that can be printed with the Coded Procedures but these procedures are not coded until the patient is discharged and it is not the most patient friendly list.
Thanks
Carrie Wood RN
Orrin Converse
I just wanted to pass on the following information. I have my interpretation, but I’m interested in how others will approach this. The measure in question is OP-19. I received word a week ago that CMS had suspended this measure. The attached message was posted by Quality Net. I had been working on a solution for our facility, and received the attached development proposal from my Meditech analyst. They tell me that this proposal is in VP Review and should begin coding soon. At this time, I have decided to hold off on our own efforts until CMS reinstates the measure or Meditech releases this update unless someone sees a problem with this approach that I haven’t considered.
Orrin Converse, RN
Grays Harbor Community Hospital
915 Anderson Drive
Aberdeen, WA
98520
(360) 590-1923
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https://cms-ocsq.custhelp.com/app/answers/detail/a_id/158792
Is measure OP-19 (Transition Record) suspended? Will the data be publicly reported or validated?
Published 03/16/2012 11:05 AM | Updated 04/02/2012 11:02 AM
Is measure OP-19 (Transition Record) suspended? Will the data be publicly reported or validated?
The Centers for Medicare & Medicaid Services (CMS) has decided to suspend this measure from public reporting and from being scored for validation purposes. However, in order for abstractions for the remaining measures for the ED Throughput Measure Set to be accepted into the clinical warehouse on My QualityNet, you must still answer the question regarding OP-19. You must still answer the question with a YES or No. The results will NOT be made public on Hospital Compare, nor used for scoring validation.
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Development Proposal #20626 "Include list of ED Procedures/Orders in Depart Packet"
** Effective for FY 2013 with encounters starting January 1, 2012, Hospitals must report statistics on the number of ED Patients who receive a Transition Record with Specified Elements Received **
Per CMS (Centers for Medicare & Medicaid Services) OP-19, the Transition Record with Specified Elements must be received by discharged patients. The transition record must contain:
All major procedures and tests performed during the Emergency Department encounter. Major procedures may include fracture management, wound repair, incision and drainage (I&D), foreign body removal, etc... Tests may include lab tests, scans, or x-rays that were performed. Tests with results pending should be included because they were performed during the encounter.
Principal clinical diagnosis OR the chief complaint (causing presentation to the ED) must be documented in the transition record at discharge.
Currently, hospitals are either using a Depart Form to manually enter the major tests/procedures on a CDS in the Departure routine, or printing the Patient Summary Report from the Tracker. This is not a streamlined workflow for busy ED nurses. To resolve this:
1) A list of all of the patient's major ED procedures and tests (which may include both LAB tests and ED treatments) should be able to print automatically from the departure routine via a Patient Summary Report.
2) The Depart Summary Report should flow to the EMR/PCI. This should be available under the Instructions header. The hospitals needs to prove, upon demand, that they are able to meet this guideline. This will have a severe financial impact if they cannot prove this information was given to the patient.
Software Requirements
Last edit 02/15/12(1156): Sullivan,Katherine G
1 [FUNCTIONAL]
A summary of the patient's major tests and procedures from his/her ED stay must print with the Depart Packet via a patient summary report.
2 [REGULATORY]
The Depart Sumary Report needs to flow to PCI/EMR so the hospital can prove, upon demand, that this information was included/printed in the patient's depart packet.
3 [FUNCTIONAL]
The patient's chief complaint must automatically print out with the depart packet (can be included on the summary report format).
4 [PATIENT SAFETY]
**Staff safety**
The hospital must have the ability to restrict whether the nurse's name prints on this depart summary report.
Details
Last edit 02/15/12(1148): Sullivan,Katherine G
1. Explain the modification in detail, and how it will improve the system. Use specific data examples.
Hospitals will have the ability to define a summary report format that can print with the patient's departure packet, directly from the Depart Routine. The customer can build the summary report to include ORD and TMT data sections, which will automatically pull the patient's tests and procedures. Many customers are already using the summary report to meet this guideline, but it cannot be printed directly from departure. Allowing the summary to print with the packet will streamline the nurses' workflow when discharging the patient.
2. Effect of change (choose 1)
Modification to Existing Features - Which features are affected?
The EDM Departure Packet is affected, as well as the EDM Customer Defined Parameters dictionary. A new parameter in the CDP's would allow hospitals to choose the format of the summary report to print the list of tests/procedures/treatments with the Packet. Additionally there will need to be a parameter to suppress the nurse's full name from printing on this summary report format.
3. How are the users currently utilizing the software without this modification?
Users are building a Depart Form in the EDM Forms dictionary and attaching a CDS that is documented during the departure process. This requires a manual build and manual re-documentation.
Additionally, users can print the Patient Summary Report with an Orders section (built in the EDM Report Format Dictionary). This cannot print with the Packet, but can be printed via the Print Multiple Reports routine or by clicking the Reports icon on the main EDM Desktop.
4. Describe the End User who would be entering the information. Include professional title. How will these users benefit from this modification?
Nurses or physicians typically perform discharge. They will benefit because the workflow will be streamlined (all from the Depart routine), and they will not have to double-document.
5. Describe the End User who would be utilizing the entered information. Include professional title. How will these users benefit from this modification?
This will be used by the patient, as it's a part of their departure packet. It could also be used by the floor if they requested a copy of the EDM Departure Packet, or by the patient's PCP for follow up care.
6. Describe the impact of the modification on the total HCIS system. Workflow of data to other departments, users, applications What if any Impact is there on clinical/financial decision making?
This will not affect the total HCIS. It's simply a change to the EDM application. It may, however, improve the work flow of data if the departed ED patient is being admitted to the hospital or is following up with a specialist after his stay in the ED.
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Julie Carlson
We’re Magic 5.64, but we have also decided to hold off on developing this until the measure is reinstated. This is the ‘official’ word our Quality Department sent out:
OP-19 ED Transition Record with specified elements received by discharged patients- the measure has been suspended! The Data will NOT be validated, published on hospital compared, nor will it affect our payment in any way!! The talk is that the measure will be clarified and re-instated at the end of this year-possibly October, or the beginning of 2013. I still have to answer all of the questions-but they don’t count for anything.
Julie Carlson
Information Systems Analyst
CASCADE VALLEY HOSPITAL AND CLINICS
Close to Home. Close to Heart.
330 S Stillaguamish Ave, Arlington, WA 98223-1603
tel. (360)618-7866
fax (360)618-7657
cell (425)220-2286
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