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Running head: SCHOLARLY PROJECT SYNTHESIS 1

Meaningful Use Scholarly Project Synthesis Paper

Jennifer Dilly

Ferris State University

August 8, 2012

2SCHOLARLY PROJECT SYNTHESIS

Abstract

The American Recovery and Reinvestment Act (ARRA) and its provision, the Health

Information Technology for Economic and Clinical Health (HITECH) Act aim to address the use

of technology for improving patient care. Using technology in a meaningful way that improves

quality of care has been termed as Meaningful Use (MU). Facilities nationwide have the

opportunity to earn financial incentives by proving their use of health information technology

complies with MU criteria. Two quality measure sets, Stroke and Venous Thromboembolism

(VTE), are part of the criteria required to comply with MU. This author describes a Scholarly

Project conducted to evaluate compliance of Spectrum Health Zeeland Community Hospital with

the measure sets. An overview of MU is provided, including criteria for attestation of

compliance related to the quality measure sets, as well as the project’s goals, objectives, and

activities. An analysis of adherence to professional performance and standards of practice

related to the project’s implementation has been provided. Recommendations for future

implementations and application of knowledge learned during the project are also included.

Keywords: Meaningful Use, quality measures, healthcare reform, nursing informatics


Meaningful Use Scholarly Project Synthesis Paper

The American Recovery and Reinvestment Act (ARRA) and its provision, the Health

Information Technology for Economic and Clinical Health (HITECH) Act, were passed in 2009

(Furukawa & Poon, 2011). The HITECH Act addresses the need for hospitals to adopt health

information technology and use it to improve health care delivery and quality of care, a term

coined as Meaningful Use (MU) (Goldschmidt, 2012). As part of MU, hospitals are required to

show how their adopted technology records and monitors certain points of patient care to earn

financial incentives. There are multiple stages of MU with Stage 1 requiring the attestation of

the capability to measure and report on different types of patient information including items

such as vital signs, smoking status, medications, allergies, patient receipt of discharge

instructions, recorded patient problem lists, and two sets of clinical quality measures (Benson,

2011). The two measure sets involve care surrounding stroke and venous thromboembolism

(VTE) for various patient populations.

According to Furukawa and Poon (2011), since the passage of ARRA and HITECH Acts,

many facilities have successfully attested to MU Stage 1. Some facilities, however, are still

adopting technology and learning the requirements for MU including how to achieve the

requirements and acquire the attached incentives. Spectrum Health Zeeland Community

Hospital (SHZCH), a facility currently adopting new health information technology, is one of

those facilities trying to learn how the MU criteria will be met. A Scholarly Project was

conducted at SHZCH to help the executive team identify how the facility will meet requirements

for MU specifically related to the Stroke and VTE measure sets. The project included

identification of gaps in the adopted technology and requirements that may still present after the

adoption, and what can be improved to close those gaps.


The intent of this paper is to present the outcomes of the Meaningful Use Scholarly

Project conducted at SHZCH. A description of the project is provided including how the project

was carried out and any issues encountered during the implementation. Personal and

professional accountability practiced during the project is addressed as is a description

surrounding the adherence to multiple standards expected from a Nursing Informatics Specialist

(NIS). Issues related to compliance with the standards are included. A self-evaluation,

evaluations from the preceptor for the project and from the presentation recipients is provided in

summarized form. Recommendations related to the project have been made. Finally a

description of the application of knowledge from theory, practice and research into the project is

included.

Project Description

The goal of the Meaningful Use Scholarly Project was to investigate how the MU

requirements, related to two of the required quality measure sets, Stroke and VTE, will be met

for the facility, and present the information to SHZCH executive team. A Planning Guide with

goals, objectives, activities and their timelines is provided in Appendix A. The goal, while

seemingly simple, required a multifaceted base of knowledge. The executive team, a

multidisciplinary team, required knowledge of not only the clinical requirements, but also

technical and financial information surrounding the requirements.

Multiple objectives were set to meet the goal, providing succinct and precise information

to the team. The first objective included obtaining and reviewing literature sources, systematic

reviews, and other pertinent information from credible web sources and subject matter experts.

All aspects of MU specific to hospital requirements were investigated including timelines and

requirements to meet the immediate and future stages, the financial implications, as well as the


technological advancements meant to help hospitals meet the requirements. Sources of

information surrounding MU and quality metrics were not hard to find. Databases in the online

library were searched for research and systematic reviews, there were multiple web sources to

search including The Centers for Medicare and Medicaid Services (CMS), various nursing

informatics sites, and other regulatory agency web sites, and a fair amount of information about

how other hospitals are or have been preparing for MU was retrieved from the electronic health

record (EHR) vendor’s web site and learning center. At one point there was almost too much

information and therefore eliminating those sources that were not as succinct as others was

necessary.

There were multiple opportunities to meet with subject matter experts in quality

departments, product analysts, leads for the main campus’ MU project, and the Spectrum Health

system’s Chief Medical Information Officer (CMIO). These experts were credible with

providing information because they have recently prepared and attested to MU for their hospital,

and in some cases, have worked on this type of readiness planning in other facilities as well.

While literature sources provide a plethora of information, the first-hand knowledge learned

from these contacts seemed to help the most.

The second objective included learning the documentation needed for the Stroke and

VTE measure sets. Quality Net (2012) is CMS’s web site source for their various quality

measure set information including all specifications for required documentation to meet each

measure and was the primary source for working with the measure sets. As the measure sets are

extensive, they needed to be identified and summarized in a succinct outline (Appendix B)

including the creation of algorithms (Appendix C) for clear understanding of what

documentation helps prove that quality care was given and each measure was met (Kallem,


2011). While the executive team may not need to understand all care points surrounding the

measures, preparation to answer any question related to the measures was still necessary.

Surprisingly, outlining and summarization of the measures took a much longer period of

time to complete. The VTE set was the first to be outlined and the original thought was since

there were fewer measures, the time taken to do so would not take as long as the Stroke set. On

the contrary, the VTE set was much lengthier and more complex because the patient populations

were not straightforward. The populations were split into three different sub-populations,

populations that included many types of patients making it difficult for caregivers to know which

patients could be included. Immediately the importance of how the system monitors what

patients may fall into this population became apparent.

The Stroke measure set outlining was not as lengthy as the VTE set, but the activity still

took an extended period of time. At this point, the need to see how many patients for this facility

would fall into this measure set became apparent as well. Although pulling data surrounding

patients who may have fallen into the populations in past years was not on the original planning

guide, time was taken to do so. The data pull revealed few patients may have been included in

the measures had they been implemented in the past. As evidenced by the data pull, the care

providers may not see these types of patients often. Care providers that may not have the chance

to practice care for these types of patients often, may remember the standards of care the

measure set is based on. A system built to guide caregivers in giving evidence-based care

becomes important (Kallem, 2011).

Once the measure sets were understood, the learning of the Cerner EHR used to capture

the documentation surrounding the measures was important. Learning the EHR included the

basic documentation system and all other tools within the system used to capture and monitor the


documentation. The learning took place by attendance in a fundamental course, by meeting with

various data abstractors, conference calls and meetings with key quality and MU leads, review of

Cerner products with system developers, review of Cerner products via web sources, and review

of Power Plans that guide ordering of treatment within Cerner for patients included in the

measure sets.

Attending the Cerner fundamental course gave a great overview of how and where

nurses and physicians document and how orders are placed. Unfortunately, the greatest

challenge in this project was that access to the build this facility is adopting was not granted.

Not having access to the system to go back and review it after the measures were outlined

hindered a detailed view of how the measures are captured as well as the completion of a

subsequent objective (a full gap assessment). Other activities, such as meeting with data

abstractors, however, facilitated some of the learning of other aspects of how the system guides

or at least monitors the provision of care. For example, the abstractors were able to show how

the system was set up to notify the caregivers of points of care within the measure set yet to be

addressed. Caregivers could address the notification by selecting choices, set up in the system as

drop down boxes, such as ‘yes’, ‘no’, ‘contraindicated’, or ‘no reason given’.

Learning the Cerner Lighthouse and eQuality check products helped with the

understanding of how to monitor care for the included population. Searching for and reviewing

information from the Cerner web site and learning center, UCern, helped with this learning. A

representative from the Spectrum Health system provided a learning session for the Lighthouse

product as well. After the learning session and the webinar for the eQuality product I was able to

ascertain what functionality this facility will have in relation to monitoring the compliance with

the measure sets.


The next objective was to perform a gap analysis, contained in Appendix D, between

needed documentation for the measure sets realized by outlining the measures, and the actual

capability of Cerner to guide caregivers in documenting necessary points of care. Performing the

gap analysis helped identify further needs for compliance with the requirements for MU

(VanAuken, Chrysler, Gricenko-Wells, & Simkin 2011). The first gap was clearly identified as

an inability to view the full Cerner documentation system built specifically for the facility. The

Cerner Lighthouse and eQuality check products, learned for the previous objective, provided the

only view of how the documentation is captured and caregivers are notified that the measure is or

is not met. Although some review was possible, without access to fully research and review the

documentation system that draws data into the Lighthouse and eQuality check products, I was

unable to fully ascertain whether the requirements for each measure’s data elements were

present, whether the data elements were written in verbiage that helped pass the measure, and

whether care givers could bypass necessary documentation to comply with each measure.

Meeting with data measure abstractors helped identify another gap including a minimal

amount of hard stops and an inability of the hard stops to actually help care providers be

reminded or stopped when care is not documented adequately. An example includes one of the

discharge summary screens for physicians. When a patient is discharged, this screen lists what

measure set the patient is in and what measures should be complied with, and the physician is

unable to move past this screen without answering. The physician is guided to answer whether a

certain medication was given, however, the measure is not considered met unless there is clear

record of administration in the medication administration record (Quality Net, 2012). Many

times the data abstractors find that there is no record of administration and the measure set is

then out of compliance (personal communication, N. Bowers, June 25, 2012).


Furthermore, there are many opportunities for care providers to free-text documentation

into the system. There is also quite a bit of scanned-in documentation such as handwritten

progress notes, hand written documentation completed in the emergency department, outside

consultations and test results. The gap in this process is evident as, per Kathy Millard an analyst

from Spectrum Health, free-text or scanned-in paper documentation does not draw into the

quality monitoring products such as Lighthouse and eQuality Check (personal communication,

July 17, 2012). Both of these products take data from the provided documentation in various

parts of the system and notify caregivers whether the measure set has been met.

The Lighthouse and eQuality Check products could prove helpful for guiding care givers,

except in cases in which the Quality Dashboards for Stroke and VTE patients are not initiated.

Lack of initiation of these dashboards is the next gap identified. There are many timed measures

in which care needs to have been given within a few hours or a few days of hospital arrival. If

the correct dashboard is not initiated, care givers will not be provided with a way to monitor

measure compliance and certain points of care could be missed. Also, if a patient was admitted

for one diagnosis and has a stroke during the admission, care givers will also need to remember

to initiate the dashboards. Failure to do this could allow for lack of compliance with the

measures.

Finally, lack of education surrounding compliance with the measures, knowledge of MU

requirements, and dashboard initiation is a gap as well. The question of who does the education

and what it contains has been posed to nursing and physician education leads as well as nursing

informatics staff. No answer regarding this has been received from the physician lead; however,

staff from the Nursing Informatics department has stated that education will be provided during


staff training on the new system. The Vice President of Physician Services has been notified

regarding the physician responsibilities related the measures as well as the dashboard initiation.

The gap analysis led to the next objective of recommending improvement suggestions

lending the hospital to be in complete compliance with MU requirements related to the measure

sets. There were a total of five recommendations made. The first recommendation included

obtaining access to the facility’s specific build. The recommendation was for the Quality

department staff, staff with a highly invested interest in the quality measure outcomes, to not

only learn the basics of the system, but also be able to search out the data points that matter in

the Stroke and VTE measures. Kallem (2011) believes that knowing the measures’ intricacies is

important, but understanding that the method for capturing data surrounding the measures in an

EHR is different and detrimental to the measure outcomes. Allowing the Quality department

staff to view how the system is set up will allow for further recommendations and ultimately

better outcomes.

Secondly, access to the Computerized Physician Order Entry (CPOE) system built for the

hospital is another recommendation. Many of the measures are dependent upon what the

physician orders. While much of the care is directed by what is ordered through the Power Plans

and measures are met by nurses documented administration of medication ordered through the

Power Plans, physicians documentation of reason for the care also need to be included. For

example, if a required medication is not ordered, physicians are expected to document the reason

why. At this point, there has been no view of what guides physicians or reminds them to

document those reasons. A view of the CPOE system may help identify what is set up to help

with compliance with Stroke and VTE measures.


Third, confirming the MU educational plans for nurses and physicians in regards to

dashboard initiation and documentation requirements is very important. The staff are currently

learning the basic documentation system and will learn more department specific functions in

subsequent courses. The leads for MU are aware that this facility has not yet implemented these

measures and that the staff will need education surrounding them. There has been assurance that

the training will take place within the department specific courses.

Furthermore, a visit to another Spectrum Health entity of like size and who has recently

adopted the same system may be helpful. A meeting with the director of quality from that other

entity has already taken place. The director has already mentioned some items that would help

the Zeeland facility have a smoother transition into using the Cerner system. Her staff has

already had to navigate through the new system and understand its functionality related to

various quality metrics including Stroke and VTE. Meeting with her staff could help the Quality

staff of the Zeeland facility understand where to look for the data points within the system and

also provide an opportunity to discuss what gaps this entity has already identified through actual

use of the system.

The final recommendation includes the need for the Quality department staff to continue

their diligence in concurrently abstracting data from charts of patients that are still admitted.

Once the patient leaves the facility, there is no more opportunity to provide certain standards of

care. Concurrently abstracting the chart could identify what care standards have not yet been

met for the patient, allowing for real-time feedback for care givers. If the quality dashboards are

not initiated, someone needs to bring this to the attention of the caregivers or initiate the

dashboard. A concurrent view of the chart will allow the need for initiation to be realized.


Presentation of the information to the executive team and the receipt of feedback

surrounding the project are the next two objectives. A power point allowed for presentation of

information and encouraged open dialogue surrounding the information. The power point

presentation was too large to provide in an appendix and therefore is provided in a separate

attachment. Providing a paper copy of the presentation to the team allowed for further reference

and note taking as well. The presentation lasted approximately 30 minutes and was attended by

all but one executive team member as well as the project’s preceptor. While there was

opportunity to ask questions at the end of the presentation, there was also open dialogue during

the presentation as well. There were a few questions asked such as how much incentive money

the hospital would earn, clarifications surrounding the objectives required for MU, what the

difference between a Power Plan and dashboard was, and if the facility was already collecting

some data surrounding the two measure sets. All questions, except for the questions regarding

how much incentive money would be earned, were able to be answered immediately.

The objective also included the administration of an evaluation tool to the executive

team. The evaluation tool (Appendix E) was created not only to ask how well the information

was presented, but also to ascertain whether the information actually helped them understand

where the facility stands in regards to meeting MU. The tool was created using a Likert Scale,

even though there are limitations to this method, it is still the most common type of scale used

(Ogden & Lo, 2001). A rating of whether the objectives of the presentation were met as well as

an opportunity to provide comments was included. There was also an extra section where the

recipients were asked what further information they would like provided. A detailed explanation

of the results follows in a subsequent section of the paper.


The final objective included the provision of feedback from the preceptor. The feedback

was meant to help identify whether the objectives have been clearly met or if there are any

opportunities for improvement for the future. The evaluation tool (Appendix F) was developed

to capture comments about whether each objective was met or exceeded and why. At the end of

the evaluation tool, the preceptor was given the chance to suggest further goals that would

facilitate the student’s learning about the project’s topic itself, or about any objectives that were

not met fully. Also included within the same tool was an opportunity to provide a

self evaluation. The detailed description of the evaluations is provided in a subsequent section of

the paper.

Personal and Professional Accountability

The American Nurses Association (ANA) outlines standards of professional performance

expected from a Nursing Informatics Specialist (NIS). There are ten standards of professional

performance; (1) education is kept current, (2) continual personal evaluation related to

professional standards adherence, (3) the enhancement of quality practice, (4) collegiality, (5)

collaboration with multidisciplinary stakeholders, (6) maintenance of professional and personal

ethics, (7) integration of research into practice, (8) utilization of appropriate resources, (9)

advocacy for patients, other providers, and organizations, and (10) the provision of leadership

within the profession (ANA, 2008). For a general informatics nurse, one without formal

graduate education, the ANA expects specific knowledge and competencies related to nursing

and informatics to be kept current. There are also further measurement criteria expected of NISs

in addition to those of general informatics nurses.

Through the scholarly project, personal and professional points of accountability were

practiced, many of which align with the ANA’s standards of professional performance. First of


all, the standard for education was met through searching and obtainment of current research

related to various points of MU and the quality measure sets. The research was reviewed and

findings applied to different parts of the project. Knowledge of quality monitoring, MU

requirements, care of stroke patients, preventative VTE care, adoption and use of health

information technology, as well as various applicable topics was gained. For instance, the topic

of alert fatigue arose during attendance in a physician driven MU meeting. The discussion

surrounding the topic was intriguing and seemed to be pertinent to nursing practice as well as for

the physicians discussing it. Literature surrounding fatigue alert was then researched for a better

understanding. For this project, alert fatigue played a part because the technology set up to guide

caregivers to adhere to the standards of care measured in the measure sets often contained alerts.

Systematic reviews such as the one by Shojania et al. (2009), addresses how alerts affect the

processes surrounding care and ultimately patient outcomes. The information in the review

facilitated the determination of whether the alerts set up in the technology products reviewed for

the project were helpful or whether they were listed as a true gap in the system.

A second professional performance standard met within the project is collegiality. The

expectation for this standard includes participation in interdisciplinary teams and knowledge

sharing between disciplines that ultimately advance nursing and informatics practice (ANA,

2009). Participation in multiple multidisciplinary meetings and conference calls throughout the

project facilitated the achievement of this standard. Power points developed by multidisciplinary

leads in the subject matter of MU requirements were also reviewed to gain knowledge from the

nursing and medical aspect of the topic. Compliance with the two measure sets requires

documentation from both nurses and physicians. The technology needed to be reviewed keeping

in mind that caregivers with varying degrees would be utilizing it all with the common goal of


providing evidence-based care. In a meeting with multidisciplinary team members from another

like-size facility, sharing of information regarding the review of the technology and its possible

gaps contributed to further discussions about other issues noted within the system. Identifying

the issues and sharing ideas for solutions leads to an enhancement of practice both for physicians

and nurses.

Moreover, sharing information and solutions to noticeable and common issues at another

facility also shows compliance with the ANA’s professional performance standard of ethics. The

ethics standard has the expectation that an NIS will inform others of issues and share ideas meant

to improve outcomes and affect healthcare delivery positively (ANA, 2009). The idea of

beneficence is a component of Larrabee’s theoretical model of quality (Larrabee, 1996).

Larrabee’s model includes beneficence in improving quality of care because caregivers are

known to work towards the common goal of doing good; providing safe, quality care. NISs meet

the standard of ethics by following Larrabee’s framework and working towards providing

caregivers accurate ways to document the provision of safe care. In this project, this standard

has been met through information sharing with another facility, affecting the care that is

provided in that other facility.

Adherence to Standards

According to Simpson (2011) there is a great divide between what he terms “Nurse

Informaticians (NI)”, those who have learned through formal educational programs, and those

who have been promoted into the position without a formal educational degree. Simpson

believes that educationally prepared NIs have the vision, understanding, and the skill set needed

to demonstrate MU. The ability to use multiple data tools to identify and extract data, sharp data

analyzing skills, and knowledge of nursing practice facilitates the revolution of raw data into


information that is truly useful in improving patient care. NIs are poised to “integrate the

meaningful use effort into the hospital’s existing quality program” and “represent nursing at

internal and external meetings related to meaningful use and overseeing the application of

standards to implementation and monitoring” (p. 83).

Through the Scholarly Project, various new technology products, Cerner Powerchart,

Lighthouse and eQuality check, useful in documenting care, pulling data, and monitoring quality

outcomes were learned. Understanding what the products are and what they are used for was

critical to the project, just as critical as understanding the measures that were being monitored.

The biggest issue identified in the project was the inability to obtain access to Powerchart, the

actual documentation piece of the system that feeds into the quality monitoring. The issue was

brought to the organization’s Vice President (VP) of Quality, but even her request for that access

was to no avail. The VP understood that knowing what the system contains to guide caregivers

through the measures would have been helpful in identifying gaps and possible improvements

(J. Czerew, VP of Clinical & Quality Systems, personal communication, May 28, 2012).

Regardless, learning the Lighthouse and eQuality products from Cerner was also considered

important for proving compliance with the MU objectives as both facilitate monitoring of

compliance with the measures and encourage caregivers to address any unmet measures while

the patient is still admitted. Assessing the functionality of these types of products in relation to

improving quality and efficiency of care, the ultimate goal of MU, aligns with what is expected

from an NIS.

Sensmeier (2011) also suggests that NIs are becoming critical in improving quality and

efficiency of care both of which affect the financial aspects of healthcare delivery. Even though

the ultimate intent of MU is to provide better care for patients, hospitals cannot forget the


financial aspect, the incentive for adoption of such technology. NIs must facilitate how

information is collected and recorded within a system and how the outcomes, both clinical and

financial, are monitored. NIs must be able to adapt and lead change in an organization and

always be innovators when preparing for the future. The financial impact of using this type of

technology to improve care has also been realized through the Scholarly Project. Research about

MU requirements was the foundation for assessing the financial impact. Learning the

technology was important in ascertaining how or if the facility can attest to compliance with MU

requirements and earn the incentives for the beginning stages of MU as well as future stages.

The ANA (2008) terms graduate prepared Nurse Informaticians, Nursing Informatics

Specialists (NIS). The ANA outlines NIS’s standards both for professional performance,

outlined previously, as well as for professional practice. There are five standards of professional

practice that all nurses in informatics must adhere to including assessment, problem and issues

identification, outcomes identification, planning, implementation, and evaluation/consultation.

NISs must also meet specific, additional measurement criteria as the ANA holds them to a higher

expectation and level of practice than generalist nurse informaticians.

The activities and outcomes of the Scholarly Project encompassed many of the standards

expected by ANA. For example, the standard for Outcomes Identification includes that NISs

identify what the expected financial outcomes related to quality and efficiency should be and

how to augment the outcomes (ANA, 2008). The intent of MU is to maximize quality and

efficiency by using technology in a meaningful way. During the Scholarly Project, assessing the

usefulness of the technology to monitor quality care, meet the requirements of MU, and earn the

financial incentive, demonstrating the adherence to the standard outlined by the ANA.


Another example of how the activities in the project demonstrated adherence to the

standards of practice for NISs is that of acting as a consultant by providing recommendations.

The ANA standard for consultation includes that an NIS is responsible for recommending ways

to resolve issues that arise (ANA, 2008). The project provided an opportunity to realize what

gaps this facility has in complying with MU. While the original intent was to review the

measures and how the facility’s Cerner build will capture documentation surrounding the

measures, access was unable to be granted for complete identification of the gaps.

Project Evaluations

As previously stated, multiple evaluations were conducted surrounding the project.

Appendix E contains the evaluations completed by the recipients of the project’s presentation.

There were only four of the five executive team members present for the presentation, but all of

them provided feedback. The feedback included some comments noting the need for further

information about certain aspects of the presentation that were not included. For example, one

team member wanted to know how much incentive the facility would earn by being compliant

with all objectives included in MU. As this facility is only able to obtain partial incentive due to

late adoption of the technology, another team member asked how many incentive dollars were

missed. Both questions were good questions, and although they were both out of the scope of

the project and presentation, information will be researched and provided to them. Overall each

question had a potential for the highest rating of five, strongly agree. As noted in the results in

the provided tool, the question that scored the lowest average, 4.25, was the question that asked

whether the information surrounding the financial implications was clear. The same question

also had the most comments noted.


Another question on the tool that had comments was that of the succinct identification of

gaps and their applicability to success. While these questions were scored as a 3 (somewhat

agree) the comments note that the gaps can only be estimated at this point in the adoption of the

system and so are challenging to identify and very unclear. Unfortunately these were questions

about gaps that could not be identified due to limited access to view the whole documentation

system.

Another evaluation tool (Appendix F) provided an avenue for self-evaluation as well as a

preceptor evaluation of the whole project. The tool provided an option to score the work as

exceeding, meeting, or not meeting each objective. The preceptor felt that all objectives

exceeded the expectations and she provided comments and examples for each. Even though she

thought expectations were exceeded, she did provide some input as to what also could have been

done to meet the objectives. For example, she recommended for the literature search objective

that contact with an expert at a governmental agency, such as CMS, could have been made to

explore a higher level view of MU. There were two objectives that in the self-evaluation I

considered only as being met and not exceeded. The reason includes the inability to view the

whole documentation system as well as the CPOE system. Perhaps a different avenue for

gaining access such as further meetings with data abstractors could have provided more views of

what was needed. Not being able to access these systems ultimately affected the complete gap

analysis.

Recommendations for Future Implementation

The first recommendation for a future similar project would first be to determine whether

access to all necessary systems can be obtained. Lack of access was a definite limiting factor in

a project that hinged greatly on it. The views of the various Cerner products were helpful, but


may have been more helpful had they occurred a little earlier in the project and further access to

investigate these products was given as well. Having more access to the product may have

helped in learning the basics of the products, something that could eventually lead to a better

mastery of what the product could do (Cooper, 2009).

Another recommendation that may have been useful, especially in obtaining more access

to the documentation system, is connecting with staff members from the Spectrum Health

Nursing Informatics department. There is no such department at the facility where the project

took place, but through contact with this staff for another project, the Nursing Informatics staff

seems to primarily function as nurse educators who train staff on technology. I understand

though, that they are also involved in looking at how the technology is serving the needs of the

care providers and ultimately affecting patient care. Perhaps connecting with various staff from

this department would provide a different view of how the staff uses the system including what

helps them the most in providing necessary documentation. I believe the staff may also be able

to describe the process for adding various data points related to quality metrics in the system (or

obtaining knowledge of who does this). Learning how they communicate and work with the

system’s quality department staff to improve processes and comply with regulatory agencies is

another opportunity that could be gained by talking with someone from the Nursing Informatics

department.

Finally, the ability to practice change management in light of unknown issues such as

limited access would also be highly useful. A study by MacPhee and Suryaprakash (2012)

showed that nurse leaders must learn and practice change management in order to effectively

complete projects and even every day responsibilities. Change management was practiced

within the project when views of the documentation system could not be accessed. Instead other


avenues such as meeting with data abstractors, viewing the quality monitoring Cerner products,

and attending fundamental system courses were pursued. Further implementation of a project

such as this may require the ability to change in light of the limitations imposed.

Application of Knowledge

There are multiple theories from nursing and non-nursing disciplines that have applied to

the scholarly project. One such model or theory, Larrabee’s model of quality care, is applicable

as the intent of complying with MU requirements aligns succinctly. Larrabee’s (1996) model

has three main concepts that interact and overlap to relate to quality and value in provision of

patient care. The main concepts include beneficence, justice, and prudence. Beneficence is

described as doing good to achieve a common goal. Justice includes achieving favorable group

goals while prudence is the focus on one’s own goals. All three concepts, prudence and justice

of caregivers working together toward the common goal of practicing beneficence or doing

what’s best for the patient, relate to the achievement of quality care. During the scholarly project

the application of Larrabee’s theory was practiced by identifying whether the facility’s

technology can truly be used to make a difference in patient outcomes through compliance with

the MU requirements. The intent of MU is to improve quality of care, the same intent shared in

Larrabee’s model.

Another theory applicable and used frequently during the project was Charles

Reigeluth’s Elaboration Theory (ET). ET is a learning theory that has been used to design

educational content program (Cooper, 2009). The idea of this learning theory is that the learner

first learns basic concepts of the instruction. Once the basics are learned, they are reviewed until

mastered before new, more advanced concepts are introduced, thus the term ‘elaboration’. The

theory allows for organization of content that facilitates knowledge to be mastered before


additional knowledge is introduced. Learners use their own perspective in gaining a deeper

meaning from the content. Learning can then continue confidently.

ET was used within the project as the stroke and VTE measure sets were learned.

Learning the measure sets and truly understanding the requirements of each needed to happen

before any knowledge of how the technology captured the required documentation was learned.

In other words, one could review the technology and its capabilities, but without knowing what

to look for within the technology, gaps would not be able to be identified. The measure sets

were extensive in their documentation requirements and so quite a bit of time was spent

reviewing and outlining the measures. In addition, to master the content of the measure sets,

algorithms outlining how each measure is or is not passed, dependent upon the documentation

provided, were created to gain a deeper meaning. The algorithms could also potentially be used

as learning content for teaching care providers in a more succinct way.

Evidence has been gathered that shows how important MU is to improving quality of

care. Crosson, Bazemore, and Phillips (2011) state that just adopting technology for use in

patient care will not automatically produce better patient outcomes, rather, they feel that the

technology must be able to be used in a way that enables better provision of care. In a

comparison study of paper versus electronic charting, these authors found that there was no

better care practiced. Further studies revealed that the poor understanding of the technology and

its usage played a part, confirming the need for caregivers to be able to use technology in a

meaningful way. The creation of or revision of existing technology to clearly guide caregivers in

meaningful usage of the technology becomes critical.

Conclusion


The scholarly project conducted intended to investigate the readiness of the facility to

comply with Meaningful Use related to the Stroke and VTE quality metrics. There were barriers

encountered during the project, as well as alternative avenues to learn information in the face of

the barriers. Overall the main goal, to present to the executive team current and future state

readiness recommendations for complying with the quality metrics required for MU, was

reached through implementation of each carefully laid out objective and embedded activities.

The project provided an excellent way to practice adherence to personal and professional

accountability to the facility served. The ANA standards of professional performance and

practice including collegiality, information sharing, planning, and implementation were also

practiced throughout the project. Evaluating is also an aspect of professional practice and was

conducted during and after the project through preceptor and self evaluations. Similar future

projects could contain some similar practices conducted in this project such as change

management. New recommendations not used in this project but thought of as helpful for similar

projects were also outlined. Finally, nursing and non-nursing theories were critical in

implementing the project as succinctly and effectively as possible.


References

American Nurses Association (ANA). (2008). Nursing informatics: Scope & standards of

practice. Washington , D.C. Nursesbooks.org.

Benson, S. (2011). Meaningful use and clinical documentation. Journal of AHIMA, 82 (2),

36-37. Retrieved from http://journal.ahima.org/2011/02/01/february-2011/

Centers for Medicare & Medicaid Services (CMS) (2012). Path to payment. Retrieved from

https://www.cms.gov/Regulations-and-

Guidance/Legislation/EHRIncentivePrograms/PathtoPayment.html

Cooper, S. (2009). Charles M. Reigeluth: Elaboration theory. Theories of Learning in

Educational Psychology. Retrieved from http://www.lifecircles-

inc.com/Learningtheories/reigeluth.html

Crosson, J. C., Bazemore, A. W., & Phillips, R. L. (2011). EHR implementation without

meaningful use can lead to worse outcomes. Graham Center Policy One-Pager.

Retrieved from www.aafp.org/afp

Furukawa, M. F. & Poon, E. (2011). Meaningful use of health information technology:

Evidence suggests benefits and challenges lie ahead. The American Journal of

Managed Care, 1, 1. Retrieved from www.ajmc.com.

Goldschmidt, K. (2012). Finding meaning in meaningful use: Understanding the health

information technology for economic and clinical health act and its impact on nursing

practice. Journal of Pediatric Nursing, 27(1), 88-89. doi:10.1016/j.pedn.2011.10.002

Kallem, C. (2011). Analyzing clinical quality measures for meaningful use. Journal of AHIMA,

82(11), 52-53. Retrieved from http://journal.ahima.org/2011/11/01/november-

december- 2011/


Larrabee, J. H. (1996). Emerging model of quality. Image: Journal of Nursing Scholarship,

28(4), 353-358. doi:10.1111/j.1547-5069.1996.tb00387.x

Macphee, M. & Suryaprakash, N. (2012) First-line nurse leaders’ health-care change

management initiatives. Journal of Nursing Management 20(2), 249–259.

doi:10.1111/j.1365-2834.2011.01338.x

Ogden, J. & Lo, J. (2011). How meaningful are data from Likert scales? An evaluation of how

ratings are made and the role of the response shift in the socially disadvantaged. Journal

of Health Psychology, 17(3), 350-361. doi: 10.1177/1359105311417192

Quality Net (2012). Specification Manual for the National Hospital Quality Measures. Retrieved

from http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic

%2FPage %2FQnetTier2&cid=1141662756099.

Sensmeier, J. (2011). Transforming nursing practice through technology and informatics.

Nursing Management, 42(11), 20-23. Retrieved from

http://journals.lww.com/nursingmanagement/pages/results.aspx?k=november%202011&

Scope=AllIssues&txtKeywords=november%202011

Shojania, K. G., Jennings, A., Mayhew, A., Ramsay, C. R., Eccles, M. P., & Grimshaw, J.

(2009). The effects of on-screen, point of care computer reminders on processes and

outcomes of care. The Cochrane Database of Systematic Reviews, (3).

doi:10.1002/14651858.CD001096.pub2

Simpson, R. L. (2011). Nurse informaticians critical to proving meaningful use. Nursing

Administration Quarterly, 35(1), 82-84. Doi:10.1097/NAQ.0b013e318203462a


Swanson, M. E., Cowan, J. M., & Blake, R. (2011). Preparation for Stage 1 Meaningful Use

attestation as an eligible hospital. ANIA-CARING Newsletter. Retrieved from

www.ania-caring.org

VanAuken, S., Chrysler, E., Gricenko Wells, L, & Simkin, M. (2011). Relating gap analysis

results to information systems program attitudes: The identification of gap priorities and

implications. Journal of Education for Business, 86(6), 346-351. doi:

10.1080/08832323.2010.538448


APPENDIX A

Project Planning GuideGoals Objectives Activities Timeline

Goal 1:

Develop an Executive level report and presentation outlining how Meaningful Use requirements, related to the Stroke and VTE quality measure sets, have been met for this facility by August 2012.

1.1

Obtain and review literature and information surrounding: Meaningful Use requirements for attestation related to the specific quality measures, and documentation requirements for Stroke and VTE measure set compliance.

1.2

Identify specific necessary documentation

1.1 a

Search Cinahl, PubMed and other databases for research and information about Meaningful Use requirements.

1.1 b

Search Quality Net for the Center for Medicare and Medicaid Services’ Specification Manual related to measure set compliance requirements

1.1 c

Compile literature and other information sources’ reference list

1.1 d

Obtain information related to the quality metrics from Spectrum Health’s lead for Meaningful Use

1.2 a

List each measure within each measure set and outline

1.1 a

Complete by June 5, 2012 - COMPLETE

1.1 b


1.1 c


1.1 d

Complete by June 5, 2012 – COMPLETE

1.2 a



requirements for each measure within each measure set

1.3

Learn the EHR system the facility will be adopting including how the EHR has been built to capture documentation surrounding the Stroke and VTE measure sets.

required documentation for each

1.3 a

Attend Cerner classes specific to nursing documentation

1.3 b

Attend Cerner CPOE classes

1.3 c

Review Cerner Lighthouse product related to quality metrics

1.3 d

Meet with Spectrum Health’s Quality department’s Stroke and VTE measure abstractors to learn specific areas of Cerner where data points related to each measure is documented

1.3 e

Review current Spectrum Health Power plans related to Stroke and VTE care

1.3 f

1.3 a

Complete by June 29, 2012 – COMPLETE

1.3 bComplete by June 29, 2012 – COMPLETE

1.3 c

Complete by June 29, 2012- COMPLETE

1.3 d

Complete by June 29, 2012- COMPLETE

1.3 e

Complete by July 6, 2012- COMPLETE

1.3 f


1.4

Perform a gap analysis for documentation needs that ensure measure set compliance and the ability to attest to the MU requirements.

1.5

As identified through the gap analysis, develop specific EHR data points that are still needed or need to be unique to this facility to meet requirements of MU and submit to facility’s Information Technology department.

1.6

Create outline of data points Cerner contains to capture documentation related to the measure sets and where in Cerner the data points are located

1.4 a

Compare previously created list of measures and required documentation with the outline of data points Cerner currently contains

1.4 b

Identify and outline the gaps between the two lists

1.5a

Submit suggestions of data points to capture necessary documentation

1.6 a

Complete by July 11, 2012- INCOMPLETE (d/t inability to view ZCH build)

1.4 a

Complete by July 16, 2012- COMPLETE

1.4 b

Complete by July 16, 2012-COMPLETE

1.5 a

Submit by July 27, 2012-REVISED: unable to view system, change to general recommendations to reach approaching Stage 2 requirements

1.6a


Prepare a report and presentation for the facility’s Executive team regarding how facility will meet MU requirements related to the two quality measure sets. Prepare an evaluation tool

1.7

Present report to Executive team and ask for feedback

1.8

Review feedback

Create a PowerPoint presentation as well as a written report for the executive team

1.6 b

Develop an evaluation tool

1.7 a

Present PowerPoint to executive team and administer evaluation tool

1.8 a

Review feedback with preceptor

1.8 b

Provide any necessary additional information to executive team and preceptor

Complete by August 1, 2012- COMPLETE

1.6 b

Complete by August 1, 2012-COMPLETE

1.7a

August 6, 2012- COMPLETE

1.8 a

August 6, 2012

1.8 b

August 8, 2012


APPENDIX B

Stroke Core MeasuresMeasures Population Data Element Names & Required

DocumentationGeneral Stroke measures Initial population:

Inpatient admissions only Patients age 18 years or older Length of Stay (LOS) ≤ 120 days

Coding: Physician documentation dictates

what the final coding becomes

STK – 1 Venous Thromboembolism (VTE) Prophylaxis

Numerator: Ischemic or hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was give on the day of or the day after hospital admission.Denominator: Ischemic or hemorrhagic stroke patients

Included: Those in the initial population ICD-9-CM Principal Diagnosis

Code for ischemic or hemorrhagic stroke (Appendix A, Table 8.1 or 8.2)

Excluded: LOS < 2 days Patients with Comfort Measures

Only documented on day of or day after hospital arrival

Patients admitted for Elective Carotid Intervention

Admission and Discharge Date Birth Date Principal Diagnosis Code Documentation of Elective Carotid

intervention Comfort Measures Only

o Progress notes re: hospice or possible hospice, order for hospice consult, order or note about comfort measures/care only.

o If documented past day after hospital arrival, patient is expected to receive VTE prophylaxis or documentation of contraindication

VTE Prophylaxiso Type of VTE documented

by nurse or physician as administered the day of or day after hospital admission. (Lovenox,


(Quality Net, 2012)

Heparin, Xaralto, Coumadin, Arixtra, SCDs).

o If only TED hose or nothing given, then need to document reason

VTE Prophylaxis Dateo Date the initial prophylaxis

was administered Reason for No VTE Prophylaxis

o If only TED hose or nothing was administered reason for not administering must be written by the day after admission

o Acceptable documentation: “No VTE Prophylaxis needed” – covers both pharmacological and mechanical, a completed assessment is marked as the patient is “low risk”, documented patient or family refusal. If reason is written “no pharmacological prophylaxis needed”, then mechanical must be given.

STK – 2 Discharged on Antithrombotic Therapy

Numerator: Ischemic stroke patients prescribed antithrombotic therapy at discharge

Included: Those in the initial patient

population Principal diagnosis code for

Ischemic stroke

Principal Diagnosis Code Discharge Disposition

o Progress notes re: hospice or possible hospice, order for hospice consult, order


Denominator: Ischemic stroke patients.

(Quality Net, 2012)

Excluded: Patients with Comfort Measures

only documented Patients admitted for elective

carotid intervention Discharge status of:

transfer to another acute care hospital

left AMA Expired Discharged to home or a

healthcare facility for hospice.

Patients with a documented reason for not prescribing antithrombotic therapy

or note about comfort measures/care only.

Elective Carotid Interventiono Documentation that the

admission was only to have this intervention performed

Antithrombotic Therapy Prescribed at Discharge

o Documentation must indicate patient is discharged on the med (medication reconciliation, discharge summary)

o If not prescribing, need to document the reason

Reason for Not Prescribing Antithrombotic Therapy at Discharge

o Reasons must be explicit and mentioned in context of antithrombotics (e.g. “active bleeding, no antithrombotic therapy”) – cannot infer that since there is a GI Bleed or other condition this is the reason.

STK – 3 Anticoagulation Therapy for Atrial Fibrillation/Flutter

Numerator: Ischemic stroke patients prescribed anticoagulation therapy at discharge.Denominator: Ischemic stroke patients with documented atrial



Ischemic stroke Patients with documented atrial

fibrillation/flutter

Admission and Discharge Date Birthdate Principal Diagnosis Code Discharge Disposition Comfort Measures Only

o Progress notes re: hospice or possible hospice, order


fibrillation/flutter.Excluded:

Patients with comfort measures only documented

Patients admitted for elective carotid intervention

Discharge status of: transfer to another acute

care hospital left AMA Expired Discharged to home or a

healthcare facility for hospice.

Patients with documented reason for not prescribing anticoagulation therapy

for hospice consult, order or note about comfort measures/care only.



Atrial Fibrillation/Fluttero History of or current

findings of atrial fibrillation or flutter anywhere in the medical record.

o History of ablation procedure

o Does not include fibrillation or flutter that terminated within 8 weeks after CABG.

Anticoagulation Therapy Prescribed at Discharge

o Includes Coumadin, Lovenox, Arixtra – see Appendix C, Table 8.3

o Documentation must indicate patient is discharged on the med (medication reconciliation, discharge summary)

o If not prescribing, need to document the reason

Reason for Not Prescribing Anticoagulation Therapy


(Quality Net, 2012)

o Reasons must be explicit and mentioned in context of anticoagulation therapy (e.g. “active bleeding, no anticoags”) – cannot infer that since there is a GI Bleed or other condition that this is the reason.

o If there is an allergy to one type, this is not a reason for not administering another type.

o Documentation of patient or caregiver refusal.

STK – 4 Thrombolytic TherapyNumerator: Ischemic stroke patients for whom IV thrombolytic therapy was initiated within 3 hours of time Last Known WellDenominator: Ischemic stroke patients whose time of arrival is within 2 hours of time Last Known Well



ischemic stroke

Excluded: Patients admitted for elective

carotid intervention Time that the patient was last

known well to arrival in the ED is greater than 2 hours

Patients with documented reason for not initiating IV thrombolytic

Admission and Discharge Date Birthdate Principal Diagnosis Code ED Patient

o Documentation of an E/M code in the ED



Arrival to ED Date and Timeo Earliest documented time

the patient arrived in the ED is taken

Last Known Wello The date and time of the

last witnessed or reported point at which the patient was asymptomatic.


(Quality Net, 2012)

o Example: “Patient/caregiver report slurred speech starting at 3 pm today”

o If patient was found with symptoms and it cannot be determined when onset was, patient is taken out of population.

Date and Time Last Known Well IV Thrombolytic Initiation

o Includes documentation of administration of Activase, Alteplase, IV t-PA, or Recombinant t-PA Tissue plasminogen activator only

IV Thrombolytic Initiation Date and Time

STK – 5 Antithrombotic Therapy by End of Hospital Day 2

Numerator: Ischemic stroke patients who had antithrombotic therapy administered by end of hospital day 2.Denominator: Ischemic stroke patients



Ischemic strokeExcluded:

LOS < 2 days Patients with Comfort Measures

only documented Patients admitted for Elective

Carotid Intervention Patients with IV or IA

Thrombolytic therapy administered at the hospital or within 24 hours of arrival

Principal Diagnosis Code Comfort Measures Only




Arrival Date IV or IA Thrombolytic Therapy

Administered at This Hospital or within 24 hours prior to Arrival


Patients with a documented reason for not administering antithrombotic therapy

o Documentation of administration of Activase, Alteplase, IV or IA t-PA, or Recombinant t-PA Tissue plasminogen activator

o If patient received one of these, patient will be taken out of this measure population

Antithrombotic Therapy Administered by End of Hospital Day 2

o Arrival day is day 1, day 2 is the next day

o Documentation must show actual administration of antithrombotic medication – see Appendix C, Table 8.2

Reason for Not Administering Antithrombotic Therapy

o Reasons must be explicit and mentioned in context of antithrombotics

o Must be documented by physician, PA, pharmacist, or NP, except in the case that the patient or family/caregiver refuses – nursing documentation may be accepted.

o Documentation must be


(Quality Net, 2012)found within the timeframe of arrival to hospital day 2.

STK – 6 Discharged on Statin MedicationNumerator: Ischemic stroke patients prescribed statin medication at dischargeDenominator: Ischemic stroke patients with an LDL ≥ 100 mg/dL, or LDL not measured, or who were on a lipid-lowering medication prior to hospital arrival.



Ischemic strokeExcluded:



Discharge status of:o Discharge to another

hospitalo AMAo Expiredo Home or another facility

for Hospice care

Principle Diagnosis Code Discharge Disposition Comfort Measures Only




Pre-arrival Lipid Lowering Agento Documentation that patient

takes a lipid lowering agent as a home medication

LDL-c Measured Within the First 48 hours or 30 days Prior to Arrival

o Documentation (lab report, handwritten notes, dictation, previous records) that LDL-c was taken within 48 hours of arrival or measures within 30 days prior to arrival

LDL-c Greater Than or Equal to 100 mg/dL

o Documentation (lab report, handwritten notes, dictation, previous records)


(Quality Net, 2012)

that LDL-c is greater than or equal to 100

o If LDL-c is lower, patient is taken out of the population

Statin Prescribed at Dischargeo Medication list at discharge

must show this type of medication prescribed (if patient’s LDL-c is greater than 100)

o If LDL-c is greater than 100 and the med is not prescribed, a reason for not doing so must be documented.

Reason for Not Prescribing a Statin at Discharge

o Allergy or adverse reaction counts as a reason for all statins not to be prescribed

o Documentation must be in the context of statins

STK – 8 Stroke EducationNumerator: Ischemic or hemorrhagic stroke patients with documentation that they or their caregivers were given education addressing all of these:

1. Activation of emergency medical system

2. Follow-up after discharge3. Medications prescribed at

Included: Patients in the initial population

(including ischemic or hemorrhagic stroke patients)

ONLY includes patients discharged to home (including patients in assisted living).

Excluded: Patients with comfort measures

Discharge Disposition Comfort measures only



admission was only to have


discharge4. Risk factors for stroke5. Warning signs and

symptoms of strokeDenominator: Ischemic stroke or hemorrhagic stroke patients discharged home.

only documented Patients not discharged to home

(including assisted living) Patients admitted for elective

carotid intervention

this intervention performed Education Addresses (all 5 pieces

must be present to receive credit, and it must be proven that the patient was given a copy of the education):

Activation of emergency medical system – How to activate in case of future stroke symptoms (e.g. “call 911 if you have XXXX symptoms)

Follow-up after discharge – information must include that the patient is to have follow-up care with a physician, physician asst., or nurse practitioner.

Medications prescribed at discharge – patient must receive a copy of medications prescribed at discharge. The list will be considered complete if the physician has signed it prior to or at discharge and it indicates that the patient received a copy.

Risk factors for stroke – educational materials must include the individual’s risk factors for stroke and must be explicit (e.g.


(Quality Net, 2012)

cannot document “decrease alcohol consumption”, must include that alcohol is a risk factor for stroke)

Warning signs and symptoms of stroke – includes education about what the warning signs of a stroke are.

STK – 10 Assessed for RehabilitationNumerator: Ischemic or hemorrhagic stroke patients assessed for or who received rehabilitation services.Denominator: Ischemic stroke or hemorrhagic stroke patients.

(Quality Net, 2012)

Included: Patients in initial patient


ischemic or hemorrhagic strokeExcluded:



Discharge status of:o Discharge to another

hospitalo AMAo Expiredo Home or another facility

for Hospice care

Discharge Disposition Comfort Measures Only




Assessed for Rehabilitation Services

o Documentation indicating patient received an assessment for or is receiving rehabilitation services (includes physician, nurse, PT/OT documentation)


Venous Thromboembolism (VTE) Core MeasuresMeasures Population Data Element Names & Required

DocumentationGeneral VTE measures Initial population:

Inpatient admissions only Age ≥ 18 LOS ≤ 120 days

Three sub-populations:1. No VTE: Patients with NO ICD-

9 Principal or other diagnosis code in Appendix A, Table 7.02, 7.03, 7.04 (multiple obstetrics codes and patients with known VTE/PE/femoral vein phlebitis, etc.)

2. Principal VTE: Patients with an ICD-9 principal diagnosis code in Appendix A, Tables 7.03 & 7.04

3. Other VTE: Patients with an ICD-9 other diagnosis code in Appendix A, Tables 7.03 & 7.04, but NO Principal diagnoses on these tables.

Coding: Physician documentation dictates

what the final coding becomesUniversal Data Elements(for all measures):

Admission date Birth date Discharge date

VTE – 1 Venous Thromboembolism (VTE) Prophylaxis

Numerator: Patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or day after hospital admission or the day of or the day after surgery end date for surgeries that start the day of

Included: All patients in the initial

population who are not in the excluded patients listed below

Excluded: LOS < two days and > 120 days Patients with comfort measures

only documented on day or of day after hospital arrival

Principal or Other Diagnosis Code Comfort Measures Only


o If documented past day after hospital arrival, patient is


or the day after hospital admission.Denominator: All patients.

Direct admits to ICU Patients transferred to ICU the

day of or the day after hospital admission with ICU LOS ≥ one day

Patients with principal diagnosis of Mental Disorder or Stroke on Appendix A, Table 7.01, 8.1, or 8.2

Patients with principal or other diagnosis codes of Obstetrics or VTE in Appendix A, Table 7.02,7.03, or 7.04

Patients with principal procedure code of SCIP VTE selected surgeries in Appendix A, Table 5.17, 5.19, 5.2, 5.21, 5.22, 5.23, 5.24.

still included in the measure ICU Admission or Transfer

o Documentation showing actual admittance to ICU

ICU Admission Dateo Order date will be used

regardless of whether the patient was physically admitted to the ICU

ICU Discharge Dateo Order date will be used

regardless of whether the patient was physically dc’d from the ICU

VTE Prophylaxiso The type of initial VTE

prophylaxis documented as administered the day of or the day after hospital admission or the day of or the day after surgery end date for surgeries that start the day of or day after hospital admission.

o Types include mechanical or pharmacological: LDUH, LMWH, SCDs, TEDs, Factor Xa Inhibitor (IV or PO), or warfarin.

VTE Prophylaxis Dateo The date the initial

prophylaxis was administered


(Quality Net, 2012)

Reason for no VTE Prophylaxiso Documentation must be

present by day after hospital admission or surgery end date

o A completed risk assessment that shows patient is at low risk, will be accepted as the reason for no VTE (including assessment on a form completed by nurses)

o For at risk patients, even if reason for no pharmacological prophylaxis is documented, the need for mechanical prophylaxis needs to be addressed.

Surgical Procedureo Documentation of a surgical

procedure using general or neuraxial anesthesia the day of or day after admission.

Surgery End DateVTE – 2 Intensive Care Unit Venous Thromboembolism (VTE) Prophylaxis

Numerator: Patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given.Denominator: Direct admits or transfers to ICU.



Excluded: LOS < two days and > 120 days Patients with comfort measures



o If documented past day after


only documented on day or of day after hospital arrival

Patients with ICU LOS < one day without VTE prophylaxis administered and documentation for no VTE prophylaxis

Patients with principal or other diagnosis codes of Obstetrics or VTE in Appendix A, Table 7.02,7.03, or 7.04

Patients with principal procedure code of SCIP VTE selected surgeries in Appendix A, Table 5.17, 5.19, 5.2, 5.21, 5.22, 5.23, and 5.24.

hospital arrival, patient is still included in the measure

ICU Admission or Transfero Documentation showing

actual admittance to ICUo Patient is not included in

this measure if not admitted to ICU

ICU Admission Dateo Can abstract actual date of

transfer or order date ICU Discharge Date

o Can take the date the order to discharge was written regardless of whether patient is physically discharged

ICU VTE Prophylaxiso Type of prophylaxis that

was actually administered the day of or day after ICU admission

o Types include mechanical or pharmacological: LDUH, LMWH, SCDs, TEDs, Factor Xa Inhibitor or warfarin.

Reason for No VTE Prophylaxis – ICU Admission

o Only physician/NP/PA or pharmacist documentation to be taken unless patient has refused, then nursing


(Quality Net, 2012)

documentation accepted.o Documentation of reason

must be written by day after ICU admission

o A completed risk assessment that shows patient is at low risk, will be accepted as the reason for no VTE (including assessment on a form completed by nurses)

o For at risk patients, even if reason for no pharmacological prophylaxis is documented, the need for mechanical prophylaxis needs to be addressed.

ICU VTE Prophylaxis Dateo Date initial prophylaxis was

administered Surgical procedure – ICU

Admissiono Documentation that a

surgical procedure using general or neuraxial anesthesia was performed the day of or day after ICU admission

Surgery End Date- ICU Admissiono Date of the surgical

procedureVTE – 3 Venous Thromboembolism Patients Included: Principal or Other Diagnosis Code


with Anticoagulation Overlap TherapyNumerator: Patients who received overlap therapy (warfarin and parenteral anticoagulation).Denominator: Patients with confirmed VTE who received warfarin.

All patients in the initial population who are not in the excluded patients listed below

Patients who received warfarin and parenteral anticoagulation:

o Five or more days with INR ≥ two prior to discontinuation of parenteral therapy OR

o Five or more days with INR < 2 and discharged on overlap therapy OR

o Less than five days and discharged on overlap therapy

Excluded: Patients < age 18 LOS > 120 days Patients with comfort measures

only Discharge disposition of:

Hospice at home or at a facility

Expired Left AMA Discharge to another

hospital Patients without warfarin therapy Patients without confirmed VTE

(by diagnostic testing)

Comfort Measures Onlyo Progress notes re: hospice or

possible hospice, order for hospice consult, order or note about comfort measures/care only.

Discharge Disposition VTE Diagnostic Test

o Documentation of a diagnostic test ofr VTE (US, venogram, CT, MRI, angiography, V/Q scan)

VTE Confirmedo Documentation of diagnosis

of VTE o Physician, NP, or PA

documentation only Warfarin Administration

o Actual administration of warfarin

Overlap Therapyo Documentation of

administration of both parenteral anticoagulation therapy and warfarin on the same day

o OR documentation or a reason why they were not administered on the same day (patient refusal or other documented reasons)

Overlap Therapy Start Dateo Date the warfarin and


(Quality Net, 2012)

anticoagulation therapies were administered/taken together

o Includes if patient is admitted, took warfarin prior to admission, and then was given anticoag therapy on the day of admission

Parenteral Anticoagulant End Dateo Date that the last parenteral

anticoagulant was administered

Parenteral Anticoagulant Prescribed at Discharge

o Documentation of anticoagulant prescribed at discharge

Reason for Discontinuation of Overlap Therapy

o Physician/NP/PA or pharmacist documentation of reason for discontinuation of overlap therapy (includes patient refusal, high INR, etc.)

VTE – 4 Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol

Numerator: Patients who have their IV UFH therapy dosages AND platelet counts monitored according to defined parameters such as a



Excluded: Patients < age 18 LOS > 120 days



o If documented past day after


nomogram or protocol.Denominator: Patients with confirmed VTE receiving IV UFH therapy.

(Quality Net, 2012)

Patients with comfort measures only

Discharge disposition of: Hospice at home or at a

facility Expired Left AMA Discharge to another

hospital Patients without UFH Therapy Patients without confirmed VTE

hospital arrival, patient is expected to receive VTE prophylaxis or documentation of contraindication





documentation only UFH Therapy Administration

o Documentation that unfractionated heparin was administered by IV

Monitoring Documentationo Documentation, orders, or

pathways that outline parameters for managing doses of IV UFH and platelet counts

o Can accept orders that state therapy ordered “per pharmacy dosing or protocol” if documentation that platelet counts are being monitored

VTE – 5 Venous Thromboembolism Included: Principal or Other Diagnosis Code


Discharge InstructionsNumerator: Patients with documentation that they or their caregivers were given written discharge instructions or other educational material about warfarin that addressed (1) compliance issues, (2) dietary advice, (3) follow-up monitoring, and (4) potential for adverse drug reactions and interactions.Denominator: Patients with confirmed VTE discharged on warfarin therapy.

All patients in the initial population who are not in the excluded patients listed below

Only includes patients discharged home, or home for hospice care

Excluded: Patients < age 18 LOS > 120 days Patients without Warfarin

prescribed at discharge Patients without confirmed VTE





documentation only Warfarin Prescribed at Discharge

o Documentation that warfarin is prescribed at discharge or is planned to restart it after discharge

Discharge Instructions Address (all 4 pieces must be present to receive credit, and it must be proven that the patient was given a copy of the education):

o Compliance Issues (must include both: importance of taking and monitoring warfarin)

o Dietary Advice (must include both: “a consistent amount” of foods with Vitamin K and avoidance of major changes in diet without notifying a health professional first)

o Follow-up Monitoring (must


(Quality Net, 2012)

include information about the plans to monitor warfarin after discharge)

o Potential for Adverse Drug Reactions and Interactions (must include all: diet and medications can affec the PT’INR level, instructions not to take or dc any meds or OTC meds without medical advice, and that warfarin increases the risk of bleeding)

VTE – 6 Incidence of Potentially-Preventable Venous Thromboembolism

Numerator: Patients who received no VTE prophylaxis prior to the VTE diagnostic test order date.Denominator: Patients who developed confirmed VTE during hospitalization.



Excluded: Patients < age 18 LOS > 120 days Patients with comfort measures

only Patients with principal diagnosis

code of VTE in Appendix A, Table 7.03 or 7.04

Patients with VTE present on admission

Patients with reasons for not administering mechanical and pharmacologic prophylaxis

Patients without VTE confirmed by diagnostic testing

Principle or Other Diagnosis Code Discharge Disposition VTE Present at Admission

o Documented VTE diagnosis or suspected the day of or day after admission

Comfort Measures Onlyo Progress notes re: hospice or

possible hospice, order for hospice consult, order or note about comfort measures/care only.

o If documented past day after hospital arrival, patient is expected to receive VTE prophylaxis or documentation of contraindication

VTE Diagnostic Testo Documentation of a


(Quality Net, 2012)

diagnostic test ofr VTE (US, venogram, CT, MRI, angiography, V/Q scan)



documentation only VTE Prophylaxis Status

o Documentation that VTE prophylaxis was administerd between the day of admission and the day prior to the diagnostic test order date OR

o Documentation physician/NP/PA/ pharmacist reason for not administering mechanical and pharmacological prophylaxis during admission


APPENDIX C

Stroke Measure Algorithms

Initial Stroke Population

Quality Net (2012). Specification manual for the National Hospital Quality Measures.


STK – 1 Venous Thromboembolism (VTE) Prophylaxis


STK – 2 Discharged on Antithrombotic Therapy


STK – 3 Anticoagulation Therapy for Atrial Fibrillation/Flutter


STK – 4 Thrombolytic Therapy


STK – 5 Antithrombotic Therapy by End of Hospital Day 2


STK – 6 Discharged on Statin Medication


STK – 8 Stroke Education


STK – 10 Assessed for Rehabilitation


VTE Measure Algorithms

Initial VTE Population

.


VTE – 1 Venous Thromboembolism (VTE) Prophylaxis

VTE -1 Cont’d


VTE – 2 Intensive Care Unit Venous Thromboembolism (VTE) Prophylaxis


VTE 2 Cont’d


VTE – 3 Venous Thromboembolism Patients with Anticoagulation Overlap Therapy


VTE-3 Cont’d


VTE – 5 Venous Thromboembolism Discharge Instructions


APPENDIX DDocumentation Capture and Gap Analysis

Measure: Data Element/Required Documentation

Data Capture Location Gap

STROKE MEASURESSTK-1: Venous Thromboembolism (VTE) Prophylaxis

1. Comfort Measures

2. Type of VTE prophylaxis administered day of or day after admission (only certain types included, date and timed measure!)

3. Reason for no prophylaxis

1. “Clin Notes” Section: Handwritten progress notes, dictated History & Physicals, Orders

2. Patient Care Summary or Medication Administration Record (MAR) Section: Nurses documentation of mechanical prophylaxis under “Antiembolic Activity”, or documentation of administration of the pharmacological type in the MAR.a) Lighthouse: dashboard

shows this as a timed measure to be addressed by physician or nurse


1. Are we relying on handwritten notes only? Does Lighthouse pick up the handwritten data to show as complete? Timed measure, if Comfort care documented on day two of admission or after, still expected to give prophylaxis – what directs this?

2. Does this direct them to enter contraindication in orders if not ordering it?Power plan says to order it as timed?

3. What prompts them to write contraindications?What if only TEDs were ordered, are


they prompted to order something else?Timed measure – does system pick up on handwritten progress note with contraindication, what if order after the time, does the system prompt to write a contraindication for not meeting the timeframe?

STK – 2: Discharged on Antithrombotic Therapy

1. Comfort Measures

2. Antithrombotic Therapy prescribed at discharge

3. Reason for not prescribing antithrombotic therapy at discharge (in context of antithrombotics)

1. See Previous notes

2. Clin Notes section: Discharge Summary is what the permanent record contains; Depart Summary with same information is what is printed and signed for patient to receive. Depart Process also has list of what measures have been addressed/met if patient is in the population.

3. Clin Notes section: Progress notes, Orders?, Depart Process list of measures

1. See previous notes: exception – patient out of measure even if documented on day 2.

2. Hard stop here for whether it is addressed or not? Depart process has a hard stop to answering questions about whether certain measures have been addressed; however, a documentation point that can be chosen is “no documented reason” is also included.

3. Same as number 2 plus, is this free text for contraindication or do they select – unknown…


STK – 3 : Anticoagulation Therapy for Atrial Fibrillation/Flutter

1. Comfort measures

2. Documented history or current atrial fib or flutter

3. Anticoagulation therapy prescribed at discharge

4. Reason for no anticoagulation therapy prescribed at discharge

1. See previous notes

2. Clin Notes section: Progress notes, Problem List


4. Clin Notes section: Progress notes, Orders?, Depart Process list of measures

1. See previous notes exception – patient out of measure even if documented on day 2.

2. Does Lighthouse pick up free text or handwritten notes (PN)?

3. Hard stop here for whether it is addressed or not? Depart process (Core Measure Summary) has a hard stop to answering questions about whether certain measures have been addressed; however, a documentation point that can be chosen is “no documented reason” is also included.

4. Same as number 3 plus, is this free text for contraindication or do they select – unknown…

STK – 4: Thrombolytic Therapy1. Date and time Last Well

Known (both must be known and explicitly documented)

2. IV thrombolytic administered (within 3 hrs of time Last Well

1. Clin Notes section: ED Supplemental, Progress Notes, H&Ps

2. MAR

1. Handwritten only, does Lighthouse pick up handwritten?

2. Timed measure – does system pick up on handwritten


Known) progress note with contraindication, what if order after the time, does the system prompt to write a contraindication for not meeting the timeframe?

STK – 5: Antithrombotic Therapy by End of Hospital Day 2

1. Comfort Measures2. IV or IA Thrombolytic

Therapy Administered at This Hospital or within 24 hours prior to Arrival

3. Antithrombotic Therapy Administered by End of Hospital Day 2

4. Reason for Not Administering Antithrombotic Therapy

1. See previous notes2. Medication Reconciliation?,

Clin Notes Section: H&P, ED Dictation. MAR.

3. MAR

4. Clin Notes: PN, H&P, ED Dictation

1. See previous notes2. Who is doing med

rec? Does Lighthouse pick up med reconciliation?

3. Does Lighthouse prompt to order? What if ordered and administered after end of day 2? Does it prompt to write a contraindication?

STK – 6: Discharged on Statin Medication

1. Comfort Measures2. Pre-arrival (home

medication) lipid lowering agent

3. LDL-c Measured Within the First 48 hours or 30 days Prior to Arrival

4. LDL-c Greater Than or Equal to 100 mg/dL

1. See previous notes2. Medication Reconciliation?

3. Flow sheet: Various lab results here. Clin Notes: H&P, Progress Notes, Consults, Problem List, Previous records, Orders.

4. Flow sheet: Various lab results here. Clin Notes: H&P, Progress Notes,

1. See previous notes2. Who is doing med

rec? Does Lighthouse pick up med reconciliation?

3. Does Lighthouse prompt to order if not done in timeframe? Does power plan direct timeframe to order or contraindication is needed to be documented?

4. Does Lighthouse pick up the lab value from


5. Statin prescribed at discharge

6. Reason for Not Prescribing a Statin at Discharge

Consults, Problem List, Previous records


6. Clin Notes: PN, H&P, ED Dictation

previous records or other scanned in documents?

5. If LDL-c drawn after timeframe, value is < 100, and no statin is ordered, does the system prompt to still provide a contraindication?

STK – 8: Stroke Education1. Comfort Measures2. Education Addresses

(all 5 pieces must be present to receive credit, and it must be proven that the patient was given a copy of the education)

1. See previous notes2. Clin Notes section:

Discharge Summary is what the permanent record contains; Depart Summary with same information is what is printed and signed for patient to receive.

1. See previous notes2. Does the Depart

Summary state “copy given to patient”.

STK – 10: Assessed for Rehabilitation

1. Comfort Measures2. Assessed for

Rehabilitation Services

1. See previous notes2. Clin Notes section: Consults,

Discharge Summary, PN.

1. See previous notes2. Where does

PT/OT/Case management document?

VENOUS THROMBOEMBOLISM (VTE) MEASURESVTE – 1: Venous Thromboembolism (VTE) Prophylaxis

1. Comfort Measures only 1. “Clin Notes” Section: Handwritten progress notes, dictated History & Physicals, Orders

1. Are we relying on handwritten notes only? Does Lighthouse pick up the handwritten data to show as complete? Timed


2. ICU Admission or Transfer (date)

3. ICU Discharge Date

4. VTE Prophylaxis (administered the day of or the day after hospital admission or the day of or the day after surgery end date for surgeries that start the day of or day after hospital admission)

5. Reason for no VTE Prophylaxis (documentation must be present by day after hospital admission or surgery end date)

6. Surgical Procedure 7. Surgery End date

2. Orders, ICU specific documentation?


4. MAR

5. Clin Notes: PN, H&P, ED Dictation, OP report

6. OP report, Anesthesia record7. OP report, Anesthesia record

measure, if Comfort care documented on day two of admission or after, still expected to give prophylaxis – what directs this?

2. Unsure whether documentation will indicate that patient is transferred to the ICU – can get date from that?

3. See previous

4. Timed measure, does Lighthouse prompt to write contraindication if not administered within timeframe?

5. Lighthouse?

6. Dictated OP note? 7. Paper anesthesia

record, scanned in, system cannot get data to Lighthouse?

VTE – 2: Intensive Care Unit Venous Thromboembolism (VTE) Prophylaxis

1. Comfort Measures only2. ICU Admission or

Transfer (date)

1. Same as VTE-12. Orders, ICU specific

documentation?

1. Same as VTE -12. Unsure whether

documentation will indicate that patient is


3. ICU Discharge DateICU VTE Prophylaxis

4. Reason for No VTE Prophylaxis – ICU Admission (Documentation of reason must be written by day after ICU admission)

5. ICU VTE Prophylaxis Date

6. Surgical procedure – ICU Admission

7. Surgery End date


4. MAR, Clin Notes: PN, H&P, ED Dictation, MAR (nursing documentation of pt refusal).

5. MAR

6. Clin Notes: OP report, anesthesia record

7. Clin Notes: OP report, anesthesia record

transferred to the ICU – can get date from that?

3. See previous

4. How does one know it is given in the ICU?

5. Does Lighthouse ask for timed documentation? Does it pick up if nurses documented ‘refused’? Where does a risk assessment happen?How does one know it is given in ICU?

6. Dependent upon handwritten documentation

7. Dependent upon handwritten documentation

VTE – 3: Venous Thromboembolism Patients with Anticoagulation Overlap Therapy

1. Comfort Measures only

2. VTE Diagnostic Test


2. Documents>Radiology flow sheet: Various test results here. Clin Notes: H&P, Progress Notes, Consults

1. Are we relying on handwritten notes only? Does Lighthouse pick up the handwritten data to show as complete?

2. Does Lighthouse pick up the test results from scanned in


3. VTE Confirmed

4. Warfarin Administration

5. Overlap Therapy (parenteral anticoagulation and warfarin therapy on same day)

3. Documents>Radiology flow sheet: Various test results here. Clin Notes: H&P, Progress Notes, Consults

4. MAR

5. MAR

documents?

3. Does Lighthouse pick up the test results from scanned in documents?

4. None

5. none


1. Comfort Measures only2. VTE Diagnostic Test3. VTE Confirmed4. UFH Therapy

Administration5. Monitoring

documentation (parameters for managing doses and platelet counts)

1. See VTE -32. See VTE-33. See VTE-34. MAR

5. Documents> various test results here. Clin Notes: H&P, Progress Notes, Consults, test results, orders

1. See VTE-32. See VTE-33. See VTE-34. None

5. Unknown – can be part of pharmacy documentation too.

VTE – 5 Venous Thromboembolism Discharge Instructions

1. VTE Diagnostic Test2. VTE Confirmed3. Warfarin Prescribed at

Discharge

4. Discharge Instructions Address (all 4 pieces

1. See VTE-32. See VTE-33. Clin Notes section:

Discharge Summary is what the permanent record contains; Depart Summary with same information is what is printed and signed for patient to receive. Depart Process also has list of what measures have been addressed/met if patient is in the population.

4. Clin Notes section: Discharge Summary is what

1. See VTE-32. See VTE-33. Previously

addressed above

4. Previously addressed


must be present to receive credit, and it must be proven that the patient was given a copy of the education)

the permanent record contains; Depart Summary with same information is what is printed and signed for patient to receive. Depart Process also has list of what measures have been addressed/met if patient is in the population.


1. No gaps

Other Identified GapsAdequate View of the ZCH Build Unable to obtain access to all points within the system that

would be necessary to document and comply with the measures. Information above was gleaned from measure abstractors from the main campus of Spectrum Health.

Hard Stops None of the measures have hard stops. Caregivers can choose to go past them without answering correctly.

Timed Measures The Lighthouse product shows a symbol (alarm clock) indicating a timed measure, however care providers must address by a certain time. The dashboard has to be initiated in a timely fashion.

Free-texted or scanned in documentation

Multiple pieces of scanned in documentation (consults, tests, hand written progress notes) will be included in the records. The Lighthouse product cannot pick up on free-texted or scanned in documentation.

Dashboard Initiation Lighthouse dashboards need to be initiated by caregivers early on in the care. If not, timed measures will be non-compliant.


APPENDIX EPresentation Evaluation and Results

Evaluation of Presentation:Compliance with Meaningful Use Requirements:

Quality Metrics – Stroke and VTE1 – Strongly Disagree 2- Disagree 3- Somewhat agree 4 – Agree 5 – Strongly Agree Results of the 4 evaluations returned are summarized in red.Objective 1: Provide an Overview of Meaningful Use

1. Components and intent of Meaningful Use were clearly understandable. 1 2 3 4 5Comments_________________________________________________No comments. Average = 4.75

2. Information surrounding the financial implications was clear.1 2 3 4 5Comments_________________________________________________Two comments: Would like to know how much money was left on the table if not meeting the requirements. Specific impact for the facility would have been helpful. Average = 3.75

3. Requirements to attest/comply with Meaningful Use and obtain incentives were succinct.1 2 3 4 5Comments_________________________________________________No comments. Average = 4.75

Objective 2: Outline the Stroke and VTE Quality Metrics included in Meaningful Use

1. It is clear what Stroke and VTE measures are included in the Meaningful Use requirements.1 2 3 4 5Comments_________________________________________________No comments. Average = 5

Objective 3: Introduce Cerner Products for Documentation and Monitoring (Lighthouse, eQuality Check, and DASH reports)

1. Each product’s capability and applicability was clearly outlined.1 2 3 4 5Comments_________________________________________________No comments. Average = 4.5

2. I understand how the product will be used within this facility to monitor compliance within the measure sets. 1 2 3 4 5Comments_________________________________________________No comments. Average = 4.5

Objective 4: Identify Gaps in Readiness to Comply with Meaningful Use Quality Metrics

1. The gaps were clearly identified.


1 2 3 4 5Comments_________________________________________________One comment: The gaps are still estimated at this point so a challenge to identify. Average = 4.25

2. Each gap and it’s applicability to success was succinctly explained.1 2 3 4 5Comments_________________________________________________One comment: Very challenging to explain when details are still uncertain or unclear. Average = 4.5

Objective 5: Provide Recommendations to Close Gaps

1. Current work to address gaps was explained.1 2 3 4 5Comments_________________________________________________No comments. Average = 4.5

2. Future recommendations identified and presented were clear. 1 2 3 4 5Comments_________________________________________________No comments: Average = 4.75

Further Information:What further information related to this presentation would you like to see?__Information related to the financial reward the specific facility would earn as well as how much money would be left on the table with only partial reimbursement._________________


APPENDIX FPreceptor and Student Evaluations

Student ____Jennifer Dilly______Preceptor ___Julianne Carey ___

For each objective, please provide comments or examples as to how objectives were exceeded, met, or not met.

Preceptor and Student Evaluation ToolObjective 1.1 Obtain and review literature and information surrounding Meaningful Use requirements for attestation related to the specific quality measures, and documentation requirements for Stroke and VTE measure set compliance.The student has researched Meaningful Use and the quality measure set compliance requirements from various databases, information sources, and through discussion with Spectrum Health’s lead for Meaningful Use. The research is evident through the provision of a literature and reference list.Preceptor Comments/Examples

Objective Exceeded Objective Met Objective Not MetJennifer completed an extensive search for literature and information. She accessed people who actively work with meaningful use with confidence and online sources including CMS which directly supports the quality of her project. The reference list is well done and thorough. I could only recommend that she possibly reach out to a representative at CMS for a deeper dive in the dialog and considerations for future metrics of meaningful use.Student Comments/Examples

Objective Exceeded Objective Met Objective Not MetThe literature search took place throughout the project and included research, systematic reviews, web sources, as well as verbal communications during meetings. I agree, after the presentation I realized I do not fully understand the


quality metrics that may be included in future meaningful use requirements – this could be found in further information seeking.Objective 1.2 Identify specific necessary documentation requirements for each measure within each measure setThe student has succinctly listed each measure within each measure sent and outlined the required documentation for each.Preceptor Comments/Examples

Objective Exceeded Objective Met Objective Not MetJennifer’s writing skills are consistently succinct and well thought out. Additionally Jennifer utilized algorithm formats and laid out the measures in a visual display that brings to focus a clear outline of Stroke and VTE measures. This work was done well and supported her work and presentation of the information to the hospital executive team.Student Comments/Examples

Objective Exceeded Objective Met Objective Not MetOutlining the measures was extremely time-consuming but necessary for understanding the rest of the project. The algorithms were an added item in anticipation of multiple questions regarding the measures.Objective 1.3 Learn the EHR system the facility will be adopting including how the EHR has been built to capture documentation surrounding the Stroke and VTE measure sets.Through attendance at various classes, the student has learned the basic documentation, computerized physician order entry, and quality metrics systems related to documentation of quality metrics for Meaningful Use. Additional meetings with Spectrum Health’s Quality department measure abstractors and review of applicable power plans has allowed the student to provide a succinct outline of data points related to documentation of the quality metrics for Meaningful Use.Preceptor Comments/Examples

Objective Exceeded Objective Met Objective Not MetJennifer’s efforts went above and beyond to access


information and functionality of the EHR product. Through her diligent work accessing leaders and vendor resources to expand her knowledge base on how the measure will be managed as well as the future applications and workflow opportunities.Student Comments/Examples

Objective Exceeded Objective Met Objective Not MetI was disappointed in not getting a full view of the CPOE product. I also hoped I would have the opportunity to view the full documentation system as it relates to Stroke and VTE. In hindsight, I believe I could have spent more time with the measure abstractors in obtaining screen shots of various data elements.

Objective 1.4 Perform a gap analysis for documentation needs that ensure measure set compliance and the ability to attest to the MU requirements.The student has compared the required documentation for each quality measure with the outline of the EHR’s data points related to documentation of the quality metrics for Meaningful Use and has effectively identified and outlined the gaps between the two. Preceptor Comments/Examples

Objective Exceeded Objective Met Objective Not MetDue to the limitations of our integration process, Jennifer had the greatest challenges with this section. Jennifer gave a strong effort to understand the gaps by working with other users of the system in like hospitals. The work was completed maximizing the available information and through analysis of the quality applications to identify the gaps that will impact achieving the meaningful use


measures.Student Comments/Examples

Objective Exceeded Objective Met Objective Not MetThe majority of the gap assessment could be complete even with the limitations. Meeting with the measure abstractors more may have increased the view of the system and enabled a more thorough gap assessment related to data element points.Objective 1.5 As identified through the gap analysis, develop specific EHR data points that are still needed or need to be unique to this facility to meet requirements of MU and submit to facility’s Information Technology department.As identified through the gap analysis, suggestions of data points necessary for capture of accurate documentation have been submitted.Preceptor Comments/Examples

Objective Exceeded Objective Met Objective Not MetThe recommendations are well thought out and articulated in the body of work. I could only suggest that Jennifer spearhead a consortium of the community hospitals in developing the support necessary to improve the EHR application for achieving the measures.Student Comments/Examples

Objective Exceeded Objective Met Objective Not MetMy original intent, to view what data points guide caregivers, was very limited leading to a limited gap analysis. I was able to focus on other aspects of monitoring compliance through other products and meeting with measure abstractors. Through these actions, I was able to supply recommendations.

Objectives 1.6 and 1.7 Prepare a report and presentation for the facility’s Executive team regarding how facility will meet MU requirements related to the two quality measure sets.


Prepare an evaluation tool. Present report to Executive team and ask for feedback. The student has created an informative PowerPoint presentation as well as a written report regarding how the facility will meet MU requirements for the two quality measure sets. The student has developed an evaluation tool to identify further information needed by the executive team. The student has effectively presented the Power Point to the executive team and obtained feedback.Preceptor Comments/Examples

Objective Exceeded Objective Met Objective Not MetJennifer’s work on this objective exceeds the expectation. The presentation was visually appealing and thoroughly presented. The executive team asked good questions and complimented Jennifer on the work done. Jennifer provided the team with a well laid out post presentation evaluation tool and strongly encouraged the team to give detailed consideration to feedback on the information that was presented. Student Comments/Examples

Objective Exceeded Objective Met Objective Not MetThe power point was designed for a specific audience and was challenging to pare down to knowledge that an executive level viewer would like to see. I asked for honest feedback so I could fully learn from the experience. There were few questions during the presentation, some were able to be answered, and others were not.Objective 1.8 Review feedbackThe student has reviewed the executive team’s feedback with the preceptor and has provided them with any additional necessary information.Preceptor Comments/Examples

Objective Exceeded Objective Met Objective Not MetJennifer complied the


feedback submitted from the Executive and is developing the information sheet that will be provided to them. Jennifer’s greatest opportunity would have been to anticipate the audience’s potential questions and expand on the financial implications of not meeting the measures.

Student Comments/ExamplesObjective Exceeded Objective Met Objective Not Met

Some unanswered questions remained after the presentation. Obtainment of information surrounding these questions has begun and will be provided to the team when available.Please provide any further SMART (specific, measureable, attainable, relevant, timed) goals recommended: I strongly recommend Jennifer emerge as a leader in the Quality department and develop a consortium among the community hospital Quality groups in effort to influence the System’s Information Technology department in the build of the EHR that will move users to completing work that efficiently and effectively documents meaningful use in the delivery of the highest quality care.

Any additional comments/suggestions.

It has been a pleasure to work with Jennifer. Her work is consistently stellar. She has effectively utilized this project in the work setting that has positioned the team in clear and effective plan to meet meaningful us measures.