CMS Quality Measure
Debbie Lake
happening swiftly. Mostly in my world the new CMS Quality Measures
for ED.
We have finally gotten it all together (I hope).
Can anyone open up the discussion what their facility process is to
meet this new measure?
Deborah J Lake RN/BSN
Clinical Coordinator
Fitzgibbon Hospital
2305 South Hwy 65
Marshall, MO 65340
660-831-3774 (direct line)
Michael Froebel R.N.
Hilo, HI 96720
MFro...@HHSC.org
Transition Record with Specified Elements Received by Discharged Patients (OP-19)
Centers for Medicare & Medicaid Services (CMS) requirement – 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.
Overview
MEDITECH must provide customers with the ability to provide a Transition Record to all departed emergency patients which includes the following data elements:
· Major procedures and tests performed during the ED visit, AND
· Principal diagnosis at discharge OR chief complaint, AND
· Patient instructions, AND
· Plan for follow-up care (OR statement that none was required), including primary physician, other health care professional, or site designated follow-up care, AND
· List of new medications and changes to continued medications the patient should take after ED discharge, with quantity prescribed and/or dispensed (OR intended duration) and instructions for each.
This document will outline the process for using the Discharge routine in order to print the Discharge Packet along with a Patient Report Format in order to provide patients with the required data elements.
MEDITECH Applications and Routines
Patient Care and Patient Safety (PCS)*
Order Management (OM)*
Emergency Department Management (EDM)*
Physician Care Manager (PCM)/Enterprise Medical Record (EMR)*
(*Indicates Requirement)
EDM Forms Dictionary
EDM Customer Defined Parameters
EDM Complaint Dictionary
EMR Formatted Data Dictionary
EMR Patient Report Format
MIS Customer Defined Data Screen (M-AT)
Outside Vendor Requirements
Discharge Instructions Content, a subscription to:
Company: Thomson Reuters Micromedex
Product: Care Notes
Company: EBSCO Publishing
Product: Patient Education Resource Center (PERC)
*MEDITECH enables organizations to create their own instructions.
MEDITECH Output Formats
Your organization can use the following reports to provide the required data elements.
- EDM Departure Packet
- Patient Summary Report Formats
- EDM Forms
MEDITECH Outline of Design Process
For sites at a release lower than 6.05 PP11 and 6.06 PP2:
Form Build
1. Build a Customer Defined Data screen that will capture major tests and procedures performed during the patient’s stay.
2. In the EDM Forms Dictionary, create a Stand Alone Discharge Form making sure to associate the CDS you created. Make sure to associate the EDM application.
3. On the Text tab of the Form Dictionary, you will need to pull in the queries associated with your CDS. In order to pull in the queries, select the Data Field button at the bottom of the screen and choose the data field Cust Def Query. This will allow you to pull in the individual queries.
4. In the EDM Complaint Dictionary, associate the form you created under the Stand Alone Form prompt. If you are using Age/Sex Overrides, make sure to associate the form here as well.
a. Please note that you will need to associate the form you created to EVERY complaint.
5. In the EDM Customer Defined Parameters, on the Discharge Tab, set the Stand Alone prompt to Y so that stand alone forms are included in your packet.
6. In Discharge, document the CDS associated with the form.
Formatted Data Build
1. Build a Formatted Data that includes the following information:
a. On the Orders Tab, include the Active, Complete and Incomplete orders for All Categories. The timeframe should be Entire Visit.
b. On the Int/Asmt/Tmt Tab, include selected interventions (treatments and/or assessments) that are considered Nursing procedures. The timeframe should be Entire Visit.
2. Create a Patient Report Format and associate your Formatted Data.
MEDITECH’s Recommended Workflow
1. When the patient is ready for discharge, the nurse should access the Discharge routine for this patient.
2. The user should select the form and click the Document button, which will launch the CDS.
3. The nurse should enter the major tests and procedures which were performed on the patient during his/her stay that were not ordered in OM or performed as a nursing intervention.
4. After the departure documentation is complete, the nurse should click the Print Packet button to print all of the patient's visit information.
5. The nurse should then select Reports button located at the bottom of the discharge routine and print the Report Format created.
Please note that if your workflow is that physicians print the packet, the physician will need to return to the tracker in order to print the report.
For sites at a release 6.05 PP11 and 6.06 PP2 and higher:
1. Build a Formatted Data that includes the following information:
a. On the Orders Tab, include the Active, Complete and Incomplete orders for All Categories. The timeframe should be Entire Visit.
b. On the Int/Asmt/Tmt Tab, include selected interventions (treatments and/or assessments) that are considered Nursing procedures. The timeframe should be Entire Visit.
c. On the Queries Tab, include selected queries for the entire visit and associate the appropriate queries utilized in your system to gather procedure information.
2. Create a Patient Report Format and associate your Formatted Data.
MEDITECH’s Recommended Workflow
1. The queries associated with Formatted Data are documented throughout the patient’s stay.
2. When the patient is ready for discharge, the nurse should access the Departure routine for this patient.
3. After the departure documentation is complete, the nurse should click the Print Packet button to print all of the patient's visit information.
4. The nurse should then select Reports button located at the bottom of the discharge routine and print the Report Format created.
Please note that if your workflow is that physicians print the packet, the physician will need to return to the tracker in order to print the report.
Supporting Documentation
Development Design Project 16121 is currently being designed to automate this process. If you have any questions regarding this proposal, please let me know.