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Meaningful Use Scholarly Project Synthesis PaperJennifer DillyFerris State UniversityAugust 8, 2012AbstractThe 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 informaticsMeaningful Use Scholarly Project Synthesis PaperThe 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 DescriptionThe 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 AccountabilityThe 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 StandardsAccording 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 EvaluationsAs 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 ImplementationThe 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 KnowledgeThere 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.ConclusionThe 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. ReferencesAmerican Nurses Association (ANA). (2008). Nursing informatics: Scope & standards of practice. Washington , D.C. . Benson, S. (2011). Meaningful use and clinical documentation. Journal of AHIMA, 82 (2), 36-37. Retrieved from for Medicare & Medicaid Services (CMS) (2012). Path to payment. Retrieved from , S. (2009). Charles M. Reigeluth: Elaboration theory. Theories of Learning in Educational Psychology. Retrieved from , 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 afpFurukawa, 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 .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.2011.10.002Kallem, C. (2011). Analyzing clinical quality measures for meaningful use. Journal of AHIMA, 82(11), 52-53. Retrieved from , 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.xOgden, 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: 10.1177/1359105311417192Quality Net (2012). Specification Manual for the National Hospital Quality Measures. Retrieved from , J. (2011). Transforming nursing practice through technology and informatics. Nursing Management, 42(11), 20-23. Retrieved from , 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.pub2Simpson, R. L. (2011). Nurse informaticians critical to proving meaningful use. Nursing Administration Quarterly, 35(1), 82-84. Doi:10.1097/NAQ.0b013e318203462aSwanson, M. E., Cowan, J. M., & Blake, R. (2011). Preparation for Stage 1 Meaningful Use attestation as an eligible hospital. ANIA-CARING Newsletter. Retrieved from ania-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:10.1080/08832323.2010.538448APPENDIX A Project Planning GuideGoalsObjectivesActivitiesTimelineGoal 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 2012.1.1Obtain 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 requirements for each measure within each measure set1.3Learn 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.1.4Perform a gap analysis for documentation needs that ensure measure set compliance and the ability to attest to the MU requirements.1.5As 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.1.6Prepare 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 tool1.7Present report to Executive team and ask for feedback1.8Review feedback1.1 aSearch 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 requirements1.1 cCompile literature and other information sources’ reference list1.1 dObtain information related to the quality metrics from Spectrum Health’s lead for Meaningful Use 1.2 aList each measure within each measure set and outline required documentation for each 1.3 aAttend Cerner classes specific to nursing documentation1.3 bAttend Cerner CPOE classes1.3 cReview Cerner Lighthouse product related to quality metrics1.3 dMeet 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 documented1.3 eReview current Spectrum Health Power plans related to Stroke and VTE care1.3 fCreate outline of data points Cerner contains to capture documentation related to the measure sets and where in Cerner the data points are located1.4 aCompare previously created list of measures and required documentation with the outline of data points Cerner currently contains 1.4 bIdentify and outline the gaps between the two lists1.5aSubmit suggestions of data points to capture necessary documentation1.6 aCreate a PowerPoint presentation as well as a written report for the executive team1.6 bDevelop an evaluation tool1.7 aPresent PowerPoint to executive team and administer evaluation tool1.8 aReview feedback with preceptor1.8 bProvide any necessary additional information to executive team and preceptor 1.1 aComplete by June 5, 2012 - COMPLETE1.1 bComplete by June 5, 2012 - COMPLETE1.1 cComplete by June 5, 2012 - COMPLETE1.1 dComplete by June 5, 2012 – COMPLETE1.2 aComplete by June 15, 2012 - COMPLETE1.3 aComplete by June 29, 2012 – COMPLETE1.3 bComplete by June 29, 2012 – COMPLETE1.3 cComplete by June 29, 2012- COMPLETE1.3 dComplete by June 29, 2012- COMPLETE1.3 eComplete by July 6, 2012- COMPLETE1.3 fComplete by July 11, 2012- INCOMPLETE (d/t inability to view ZCH build)1.4 aComplete by July 16, 2012- COMPLETE1.4 bComplete by July 16, 2012-COMPLETE1.5 aSubmit by July 27, 2012-REVISED: unable to view system, change to general recommendations to reach approaching Stage 2 requirements1.6aComplete by August 1, 2012- COMPLETE1.6 bComplete by August 1, 2012-COMPLETE1.7aAugust 6, 2012- COMPLETE1.8 aAugust 6, 20121.8 bAugust 8, 2012APPENDIX BStroke Core MeasuresMeasuresPopulationData Element Names & Required DocumentationGeneral Stroke measuresInitial population:Inpatient admissions onlyPatients age 18 years or olderLength of Stay (LOS) ≤ 120 daysCoding:Physician documentation dictates what the final coding becomesSTK – 1 Venous Thromboembolism (VTE) ProphylaxisNumerator: 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(Quality Net, 2012)Included:Those in the initial populationICD-9-CM Principal Diagnosis Code for ischemic or hemorrhagic stroke (Appendix A, Table 8.1 or 8.2)Excluded:LOS < 2 daysPatients with Comfort Measures Only documented on day of or day after hospital arrivalPatients admitted for Elective Carotid InterventionAdmission and Discharge DateBirth DatePrincipal Diagnosis CodeDocumentation of Elective Carotid interventionComfort Measures OnlyProgress notes re: hospice or possible hospice, order for hospice consult, order or note about comfort measures/care only.If documented past day after hospital arrival, patient is expected to receive VTE prophylaxis or documentation of contraindicationVTE ProphylaxisType of VTE documented by nurse or physician as administered the day of or day after hospital admission. (Lovenox, Heparin, Xaralto, Coumadin, Arixtra, SCDs). If only TED hose or nothing given, then need to document reasonVTE Prophylaxis DateDate the initial prophylaxis was administered Reason for No VTE ProphylaxisIf only TED hose or nothing was administered reason for not administering must be written by the day after admissionAcceptable 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 TherapyNumerator: Ischemic stroke patients prescribed antithrombotic therapy at dischargeDenominator: Ischemic stroke patients.(Quality Net, 2012)Included:Those in the initial patient population Principal diagnosis code for Ischemic strokeExcluded:Patients with Comfort Measures only documentedPatients admitted for elective carotid interventionDischarge status of: transfer to another acute care hospital left AMA ExpiredDischarged to home or a healthcare facility for hospice.Patients with a documented reason for not prescribing antithrombotic therapyPrincipal Diagnosis CodeDischarge DispositionProgress notes re: hospice or possible hospice, order for hospice consult, order or note about comfort measures/care only.Elective Carotid InterventionDocumentation that the admission was only to have this intervention performedAntithrombotic Therapy Prescribed at DischargeDocumentation must indicate patient is discharged on the med (medication reconciliation, discharge summary)If not prescribing, need to document the reasonReason for Not Prescribing Antithrombotic Therapy at DischargeReasons 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/FlutterNumerator: Ischemic stroke patients prescribed anticoagulation therapy at discharge.Denominator: Ischemic stroke patients with documented atrial fibrillation/flutter.(Quality Net, 2012)Included:Those in the initial patient population Principal diagnosis code for Ischemic strokePatients with documented atrial fibrillation/flutterExcluded:Patients with comfort measures only documentedPatients admitted for elective carotid interventionDischarge status of: transfer to another acute care hospital left AMA ExpiredDischarged to home or a healthcare facility for hospice.Patients with documented reason for not prescribing anticoagulation therapyAdmission and Discharge DateBirthdatePrincipal Diagnosis CodeDischarge DispositionComfort Measures OnlyProgress notes re: hospice or possible hospice, order for hospice consult, order or note about comfort measures/care only.Elective Carotid InterventionDocumentation that the admission was only to have this intervention performedAtrial Fibrillation/FlutterHistory of or current findings of atrial fibrillation or flutter anywhere in the medical record.History of ablation procedureDoes not include fibrillation or flutter that terminated within 8 weeks after CABG.Anticoagulation Therapy Prescribed at Discharge Includes Coumadin, Lovenox, Arixtra – see Appendix C, Table 8.3Documentation must indicate patient is discharged on the med (medication reconciliation, discharge summary)If not prescribing, need to document the reasonReason for Not Prescribing Anticoagulation TherapyReasons 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.If there is an allergy to one type, this is not a reason for not administering another type.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(Quality Net, 2012)Included:Those in the initial patient population Principal diagnosis code for ischemic strokeExcluded:Patients admitted for elective carotid interventionTime that the patient was last known well to arrival in the ED is greater than 2 hoursPatients with documented reason for not initiating IV thrombolyticAdmission and Discharge DateBirthdatePrincipal Diagnosis CodeED PatientDocumentation of an E/M code in the EDElective Carotid InterventionDocumentation that the admission was only to have this intervention performedArrival to ED Date and TimeEarliest documented time the patient arrived in the ED is takenLast Known WellThe date and time of the last witnessed or reported point at which the patient was asymptomatic.Example: “Patient/caregiver report slurred speech starting at 3 pm today”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 WellIV Thrombolytic InitiationIncludes documentation of administration of Activase, Alteplase, IV t-PA, or Recombinant t-PA Tissue plasminogen activator onlyIV Thrombolytic Initiation Date and TimeSTK – 5 Antithrombotic Therapy by End of Hospital Day 2Numerator: Ischemic stroke patients who had antithrombotic therapy administered by end of hospital day 2.Denominator: Ischemic stroke patients(Quality Net, 2012)Included:Those in the initial patient population Principal diagnosis code for Ischemic strokeExcluded:LOS < 2 daysPatients with Comfort Measures only documentedPatients admitted for Elective Carotid InterventionPatients with IV or IA Thrombolytic therapy administered at the hospital or within 24 hours of arrivalPatients with a documented reason for not administering antithrombotic therapyPrincipal Diagnosis CodeComfort Measures OnlyProgress notes re: hospice or possible hospice, order for hospice consult, order or note about comfort measures/care only.Elective Carotid InterventionDocumentation that the admission was only to have this intervention performedArrival DateIV or IA Thrombolytic Therapy Administered at This Hospital or within 24 hours prior to ArrivalDocumentation of administration of Activase, Alteplase, IV or IA t-PA, or Recombinant t-PA Tissue plasminogen activator If patient received one of these, patient will be taken out of this measure populationAntithrombotic Therapy Administered by End of Hospital Day 2Arrival day is day 1, day 2 is the next dayDocumentation must show actual administration of antithrombotic medication – see Appendix C, Table 8.2Reason for Not Administering Antithrombotic Therapy Reasons must be explicit and mentioned in context of antithrombotics 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.Documentation must be 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.(Quality Net, 2012)Included:Those in the initial patient population Principal diagnosis code for Ischemic strokeExcluded:Patients with comfort measures only documentedPatients admitted for elective carotid interventionDischarge status of:Discharge to another hospitalAMAExpiredHome or another facility for Hospice carePrinciple Diagnosis CodeDischarge DispositionComfort Measures OnlyProgress notes re: hospice or possible hospice, order for hospice consult, order or note about comfort measures/care only.Elective Carotid InterventionDocumentation that the admission was only to have this intervention performedPre-arrival Lipid Lowering AgentDocumentation that patient takes a lipid lowering agent as a home medicationLDL-c Measured Within the First 48 hours or 30 days Prior to ArrivalDocumentation (lab report, handwritten notes, dictation, previous records) that LDL-c was taken within 48 hours of arrival or measures within 30 days prior to arrivalLDL-c Greater Than or Equal to 100 mg/dLDocumentation (lab report, handwritten notes, dictation, previous records) that LDL-c is greater than or equal to 100If LDL-c is lower, patient is taken out of the populationStatin Prescribed at DischargeMedication list at discharge must show this type of medication prescribed (if patient’s LDL-c is greater than 100)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 DischargeAllergy or adverse reaction counts as a reason for all statins not to be prescribedDocumentation must be in the context of statinsSTK – 8 Stroke EducationNumerator: Ischemic or hemorrhagic stroke patients with documentation that they or their caregivers were given education addressing all of these:Activation of emergency medical systemFollow-up after dischargeMedications prescribed at dischargeRisk factors for strokeWarning signs and symptoms of strokeDenominator: Ischemic stroke or hemorrhagic stroke patients discharged home.(Quality Net, 2012)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 only documentedPatients not discharged to home (including assisted living)Patients admitted for elective carotid interventionDischarge DispositionComfort measures onlyProgress notes re: hospice or possible hospice, order for hospice consult, order or note about comfort measures/care only.Elective Carotid InterventionDocumentation that the admission was only to have this intervention performedEducation 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. 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 populationPrincipal diagnosis code for ischemic or hemorrhagic strokeExcluded:Patients with comfort measures only documentedPatients admitted for elective carotid interventionDischarge status of:Discharge to another hospitalAMAExpiredHome or another facility for Hospice careDischarge DispositionComfort Measures OnlyProgress notes re: hospice or possible hospice, order for hospice consult, order or note about comfort measures/care only.Elective Carotid InterventionDocumentation that the admission was only to have this intervention performedAssessed for Rehabilitation ServicesDocumentation indicating patient received an assessment for or is receiving rehabilitation services (includes physician, nurse, PT/OT documentation)Venous Thromboembolism (VTE) Core MeasuresMeasuresPopulationData Element Names & Required DocumentationGeneral VTE measuresInitial population:Inpatient admissions onlyAge ≥ 18LOS ≤ 120 daysThree sub-populations: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.)Principal VTE: Patients with an ICD-9 principal diagnosis code in Appendix A, Tables 7.03 & 7.04Other 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 dateBirth dateDischarge dateVTE – 1 Venous Thromboembolism (VTE) ProphylaxisNumerator: 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 or the day after hospital admission.Denominator: All patients.(Quality Net, 2012)Included:All patients in the initial population who are not in the excluded patients listed belowExcluded:LOS < two days and > 120 daysPatients with comfort measures only documented on day or of day after hospital arrivalDirect admits to ICUPatients transferred to ICU the day of or the day after hospital admission with ICU LOS ≥ one dayPatients with principal diagnosis of Mental Disorder or Stroke on Appendix A, Table 7.01, 8.1, or 8.2Patients with principal or other diagnosis codes of Obstetrics or VTE in Appendix A, Table 7.02,7.03, or 7.04Patients 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.Principal or Other Diagnosis CodeComfort Measures OnlyProgress notes re: hospice or possible hospice, order for hospice consult, order or note about comfort measures/care only.If documented past day after hospital arrival, patient is still included in the measureICU Admission or TransferDocumentation showing actual admittance to ICUICU Admission DateOrder date will be used regardless of whether the patient was physically admitted to the ICUICU Discharge DateOrder date will be used regardless of whether the patient was physically dc’d from the ICUVTE ProphylaxisThe 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.Types include mechanical or pharmacological: LDUH, LMWH, SCDs, TEDs, Factor Xa Inhibitor (IV or PO), or warfarin.VTE Prophylaxis DateThe date the initial prophylaxis was administeredReason for no VTE ProphylaxisDocumentation must be present by day after hospital admission or surgery end dateA 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)For at risk patients, even if reason for no pharmacological prophylaxis is documented, the need for mechanical prophylaxis needs to be addressed.Surgical ProcedureDocumentation 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) ProphylaxisNumerator: Patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given.Denominator: Direct admits or transfers to ICU.(Quality Net, 2012)Included:All patients in the initial population who are not in the excluded patients listed belowExcluded:LOS < two days and > 120 daysPatients with comfort measures only documented on day or of day after hospital arrivalPatients with ICU LOS < one day without VTE prophylaxis administered and documentation for no VTE prophylaxisPatients with principal or other diagnosis codes of Obstetrics or VTE in Appendix A, Table 7.02,7.03, or 7.04Patients 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.Principal or Other Diagnosis CodeComfort Measures OnlyProgress notes re: hospice or possible hospice, order for hospice consult, order or note about comfort measures/care only.If documented past day after hospital arrival, patient is still included in the measureICU Admission or TransferDocumentation showing actual admittance to ICUPatient is not included in this measure if not admitted to ICUICU Admission DateCan abstract actual date of transfer or order dateICU Discharge DateCan take the date the order to discharge was written regardless of whether patient is physically dischargedICU VTE ProphylaxisType of prophylaxis that was actually administered the day of or day after ICU admissionTypes include mechanical or pharmacological: LDUH, LMWH, SCDs, TEDs, Factor Xa Inhibitor or warfarin.Reason for No VTE Prophylaxis – ICU AdmissionOnly physician/NP/PA or pharmacist documentation to be taken unless patient has refused, then nursing documentation accepted.Documentation of reason must be written by day after ICU admissionA 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)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 DateDate initial prophylaxis was administeredSurgical procedure – ICU AdmissionDocumentation that a surgical procedure using general or neuraxial anesthesia was performed the day of or day after ICU admission Surgery End Date- ICU AdmissionDate of the surgical procedureVTE – 3 Venous Thromboembolism Patients with Anticoagulation Overlap TherapyNumerator: Patients who received overlap therapy (warfarin and parenteral anticoagulation).Denominator: Patients with confirmed VTE who received warfarin.(Quality Net, 2012)Included:All patients in the initial population who are not in the excluded patients listed belowPatients who received warfarin and parenteral anticoagulation:Five or more days with INR ≥ two prior to discontinuation of parenteral therapy ORFive or more days with INR < 2 and discharged on overlap therapy ORLess than five days and discharged on overlap therapy Excluded:Patients < age 18LOS > 120 daysPatients with comfort measures onlyDischarge disposition of:Hospice at home or at a facilityExpiredLeft AMADischarge to another hospitalPatients without warfarin therapyPatients without confirmed VTE (by diagnostic testing)Principal or Other Diagnosis CodeComfort Measures OnlyProgress notes re: hospice or possible hospice, order for hospice consult, order or note about comfort measures/care only.Discharge DispositionVTE Diagnostic TestDocumentation of a diagnostic test ofr VTE (US, venogram, CT, MRI, angiography, V/Q scan)VTE ConfirmedDocumentation of diagnosis of VTE Physician, NP, or PA documentation onlyWarfarin AdministrationActual administration of warfarin Overlap TherapyDocumentation of administration of both parenteral anticoagulation therapy and warfarin on the same dayOR documentation or a reason why they were not administered on the same day (patient refusal or other documented reasons)Overlap Therapy Start DateDate the warfarin and anticoagulation therapies were administered/taken togetherIncludes if patient is admitted, took warfarin prior to admission, and then was given anticoag therapy on the day of admissionParenteral Anticoagulant End DateDate that the last parenteral anticoagulant was administeredParenteral Anticoagulant Prescribed at DischargeDocumentation of anticoagulant prescribed at dischargeReason for Discontinuation of Overlap TherapyPhysician/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 ProtocolNumerator: Patients who have their IV UFH therapy dosages AND platelet counts monitored according to defined parameters such as a nomogram or protocol.Denominator: Patients with confirmed VTE receiving IV UFH therapy.(Quality Net, 2012)Included:All patients in the initial population who are not in the excluded patients listed belowExcluded:Patients < age 18LOS > 120 daysPatients with comfort measures onlyDischarge disposition of:Hospice at home or at a facilityExpiredLeft AMADischarge to another hospitalPatients without UFH Therapy Patients without confirmed VTE Principal or Other Diagnosis CodeComfort Measures OnlyProgress notes re: hospice or possible hospice, order for hospice consult, order or note about comfort measures/care only.If documented past day after hospital arrival, patient is expected to receive VTE prophylaxis or documentation of contraindicationDischarge DispositionVTE Diagnostic TestDocumentation of a diagnostic test ofr VTE (US, venogram, CT, MRI, angiography, V/Q scan)VTE ConfirmedDocumentation of diagnosis of VTE Physician, NP, or PA documentation onlyUFH Therapy AdministrationDocumentation that unfractionated heparin was administered by IVMonitoring DocumentationDocumentation, orders, or pathways that outline parameters for managing doses of IV UFH and platelet countsCan accept orders that state therapy ordered “per pharmacy dosing or protocol” if documentation that platelet counts are being monitoredVTE – 5 Venous Thromboembolism 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.(Quality Net, 2012)Included:All patients in the initial population who are not in the excluded patients listed belowOnly includes patients discharged home, or home for hospice careExcluded:Patients < age 18LOS > 120 daysPatients without Warfarin prescribed at dischargePatients without confirmed VTE Principal or Other Diagnosis CodeDischarge DispositionVTE Diagnostic TestDocumentation of a diagnostic test ofr VTE (US, venogram, CT, MRI, angiography, V/Q scan)VTE ConfirmedDocumentation of diagnosis of VTE Physician, NP, or PA documentation onlyWarfarin Prescribed at DischargeDocumentation that warfarin is prescribed at discharge or is planned to restart it after dischargeDischarge 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):Compliance Issues (must include both: importance of taking and monitoring warfarin)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)Follow-up Monitoring (must include information about the plans to monitor warfarin after discharge)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 ThromboembolismNumerator: Patients who received no VTE prophylaxis prior to the VTE diagnostic test order date.Denominator: Patients who developed confirmed VTE during hospitalization.(Quality Net, 2012)Included:All patients in the initial population who are not in the excluded patients listed belowExcluded:Patients < age 18LOS > 120 daysPatients with comfort measures onlyPatients with principal diagnosis code of VTE in Appendix A, Table 7.03 or 7.04Patients with VTE present on admissionPatients with reasons for not administering mechanical and pharmacologic prophylaxisPatients without VTE confirmed by diagnostic testingPrinciple or Other Diagnosis CodeDischarge DispositionVTE Present at AdmissionDocumented VTE diagnosis or suspected the day of or day after admissionComfort Measures OnlyProgress notes re: hospice or possible hospice, order for hospice consult, order or note about comfort measures/care only.If documented past day after hospital arrival, patient is expected to receive VTE prophylaxis or documentation of contraindicationVTE Diagnostic TestDocumentation of a diagnostic test ofr VTE (US, venogram, CT, MRI, angiography, V/Q scan)VTE ConfirmedDocumentation of diagnosis of VTE Physician, NP, or PA documentation onlyVTE Prophylaxis StatusDocumentation that VTE prophylaxis was administerd between the day of admission and the day prior to the diagnostic test order date ORDocumentation physician/NP/PA/ pharmacist reason for not administering mechanical and pharmacological prophylaxis during admissionAPPENDIX CStroke Measure AlgorithmsInitial Stroke PopulationQuality Net (2012). Specification manual for the National Hospital Quality Measures. STK – 1 Venous Thromboembolism (VTE) ProphylaxisSTK – 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 AlgorithmsInitial VTE Population. VTE – 1 Venous Thromboembolism (VTE) Prophylaxis VTE -1 Cont’d VTE – 2 Intensive Care Unit Venous Thromboembolism (VTE) ProphylaxisVTE 2 Cont’dVTE – 3 Venous Thromboembolism Patients with Anticoagulation Overlap TherapyVTE-3 Cont’dVTE – 4 Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by ProtocolVTE – 5 Venous Thromboembolism Discharge InstructionsVTE – 6 Incidence of Potentially-Preventable Venous ThromboembolismAPPENDIX DDocumentation Capture and Gap AnalysisMeasure: Data Element/Required DocumentationData Capture LocationGapSTROKE MEASURESSTK-1: Venous Thromboembolism (VTE) ProphylaxisComfort MeasuresType of VTE prophylaxis administered day of or day after admission (only certain types included, date and timed measure!)Reason for no prophylaxis“Clin Notes” Section: Handwritten progress notes, dictated History & Physicals, OrdersPatient 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.Lighthouse: dashboard shows this as a timed measure to be addressed by physician or nurse“Clin Notes” Section: Handwritten progress notes, dictated History & Physicals, OrdersAre 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?Does this direct them to enter contraindication in orders if not ordering it?Power plan says to order it as timed?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 TherapyComfort MeasuresAntithrombotic Therapy prescribed at dischargeReason for not prescribing antithrombotic therapy at discharge (in context of antithrombotics)See Previous notesClin 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.Clin Notes section: Progress notes, Orders?, Depart Process list of measuresSee previous notes: exception – patient out of measure even if documented on day 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.Same as number 2 plus, is this free text for contraindication or do they select – unknown…STK – 3 : Anticoagulation Therapy for Atrial Fibrillation/FlutterComfort measuresDocumented history or current atrial fib or flutterAnticoagulation therapy prescribed at dischargeReason for no anticoagulation therapy prescribed at dischargeSee previous notesClin Notes section: Progress notes, Problem List 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.Clin Notes section: Progress notes, Orders?, Depart Process list of measuresSee previous notes exception – patient out of measure even if documented on day 2.Does Lighthouse pick up free text or handwritten notes (PN)?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.Same as number 3 plus, is this free text for contraindication or do they select – unknown…STK – 4: Thrombolytic TherapyDate and time Last Well Known (both must be known and explicitly documented)IV thrombolytic administered (within 3 hrs of time Last Well Known)Clin Notes section: ED Supplemental, Progress Notes, H&PsMARHandwritten only, does Lighthouse pick up handwritten?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 – 5: Antithrombotic Therapy by End of Hospital Day 2Comfort MeasuresIV or IA Thrombolytic Therapy Administered at This Hospital or within 24 hours prior to ArrivalAntithrombotic Therapy Administered by End of Hospital Day 2Reason for Not Administering Antithrombotic TherapySee previous notesMedication Reconciliation?, Clin Notes Section: H&P, ED Dictation. MAR.MARClin Notes: PN, H&P, ED DictationSee previous notesWho is doing med rec? Does Lighthouse pick up med reconciliation?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 MedicationComfort MeasuresPre-arrival (home medication) lipid lowering agentLDL-c Measured Within the First 48 hours or 30 days Prior to ArrivalLDL-c Greater Than or Equal to 100 mg/dLStatin prescribed at dischargeReason for Not Prescribing a Statin at DischargeSee previous notesMedication Reconciliation?Flow sheet: Various lab results here. Clin Notes: H&P, Progress Notes, Consults, Problem List, Previous records, Orders.Flow sheet: Various lab results here. Clin Notes: H&P, Progress Notes, Consults, Problem List, Previous recordsClin 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.Clin Notes: PN, H&P, ED Dictation See previous notesWho is doing med rec? Does Lighthouse pick up med reconciliation?Does Lighthouse prompt to order if not done in timeframe? Does power plan direct timeframe to order or contraindication is needed to be documented?Does Lighthouse pick up the lab value from previous records or other scanned in documents?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 EducationComfort MeasuresEducation 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)See previous notesClin 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. See previous notesDoes the Depart Summary state “copy given to patient”.STK – 10: Assessed for RehabilitationComfort MeasuresAssessed for Rehabilitation ServicesSee previous notesClin Notes section: Consults, Discharge Summary, PN. See previous notesWhere does PT/OT/Case management document?VENOUS THROMBOEMBOLISM (VTE) MEASURESVTE – 1: Venous Thromboembolism (VTE) ProphylaxisComfort Measures onlyICU Admission or Transfer (date)ICU Discharge DateVTE 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)Reason for no VTE Prophylaxis (documentation must be present by day after hospital admission or surgery end date)Surgical Procedure Surgery End date“Clin Notes” Section: Handwritten progress notes, dictated History & Physicals, OrdersOrders, ICU specific documentation?Orders, ICU specific documentation?MARClin Notes: PN, H&P, ED Dictation, OP reportOP report, Anesthesia recordOP report, Anesthesia recordAre 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?Unsure whether documentation will indicate that patient is transferred to the ICU – can get date from that?See previousTimed measure, does Lighthouse prompt to write contraindication if not administered within timeframe?Lighthouse?Dictated OP note? Paper anesthesia record, scanned in, system cannot get data to Lighthouse?VTE – 2: Intensive Care Unit Venous Thromboembolism (VTE) ProphylaxisComfort Measures onlyICU Admission or Transfer (date)ICU Discharge DateICU VTE ProphylaxisReason for No VTE Prophylaxis – ICU Admission (Documentation of reason must be written by day after ICU admission)ICU VTE Prophylaxis DateSurgical procedure – ICU Admission Surgery End dateSame as VTE-1Orders, ICU specific documentation?Orders, ICU specific documentation?MAR, Clin Notes: PN, H&P, ED Dictation, MAR (nursing documentation of pt refusal). MARClin Notes: OP report, anesthesia recordClin Notes: OP report, anesthesia recordSame as VTE -1Unsure whether documentation will indicate that patient is transferred to the ICU – can get date from that?See previousHow does one know it is given in the ICU?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?Dependent upon handwritten documentationDependent upon handwritten documentationVTE – 3: Venous Thromboembolism Patients with Anticoagulation Overlap TherapyComfort Measures onlyVTE Diagnostic TestVTE ConfirmedWarfarin AdministrationOverlap Therapy (parenteral anticoagulation and warfarin therapy on same day)“Clin Notes” Section: Handwritten progress notes, dictated History & Physicals, OrdersDocuments>Radiology flow sheet: Various test results here. Clin Notes: H&P, Progress Notes, ConsultsDocuments>Radiology flow sheet: Various test results here. Clin Notes: H&P, Progress Notes, ConsultsMARMARAre we relying on handwritten notes only? Does Lighthouse pick up the handwritten data to show as complete? Does Lighthouse pick up the test results from scanned in documents?Does Lighthouse pick up the test results from scanned in documents?NonenoneVTE – 4 Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by ProtocolComfort Measures onlyVTE Diagnostic TestVTE ConfirmedUFH Therapy AdministrationMonitoring documentation (parameters for managing doses and platelet counts)See VTE -3See VTE-3See VTE-3MARDocuments> various test results here. Clin Notes: H&P, Progress Notes, Consults, test results, ordersSee VTE-3See VTE-3See VTE-3NoneUnknown – can be part of pharmacy documentation too.VTE – 5 Venous Thromboembolism Discharge InstructionsVTE Diagnostic TestVTE ConfirmedWarfarin Prescribed at DischargeDischarge 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)See VTE-3See VTE-3Clin 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.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.See VTE-3See VTE-3Previously addressed abovePreviously addressedVTE – 6 Incidence of Potentially-Preventable Venous ThromboembolismNo gapsOther Identified GapsAdequate View of the ZCH BuildUnable 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 StopsNone of the measures have hard stops. Caregivers can choose to go past them without answering correctly.Timed MeasuresThe 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 documentationMultiple 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 InitiationLighthouse dashboards need to be initiated by caregivers early on in the care. If not, timed measures will be non-compliant.APPENDIX EPresentation Evaluation and ResultsEvaluation 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 UseComponents and intent of Meaningful Use were clearly understandable. 1 2 3 4 5Comments_________________________________________________No comments. Average = 4.75Information 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 = 3.75Requirements to attest/comply with Meaningful Use and obtain incentives were succinct.1 2 3 4 5Comments_________________________________________________No comments. Average = 4.75Objective 2: Outline the Stroke and VTE Quality Metrics included in Meaningful UseIt is clear what Stroke and VTE measures are included in the Meaningful Use requirements.1 2 3 4 5Comments_________________________________________________No comments. Average = 5Objective 3: Introduce Cerner Products for Documentation and Monitoring (Lighthouse, eQuality Check, and DASH reports)Each product’s capability and applicability was clearly outlined.1 2 3 4 5Comments_________________________________________________No comments. Average = 4.5I 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 = 4.5Objective 4: Identify Gaps in Readiness to Comply with Meaningful Use Quality MetricsThe 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 = 4.25Each 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 = 4.5Objective 5: Provide Recommendations to Close GapsCurrent work to address gaps was explained.1 2 3 4 5Comments_________________________________________________No comments. Average = 4.5Future 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/ExamplesObjective ExceededObjective MetObjective 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/ExamplesObjective ExceededObjective MetObjective 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/ExamplesObjective ExceededObjective MetObjective 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/ExamplesObjective ExceededObjective MetObjective 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 ExceededObjective MetObjective 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/ExamplesObjective ExceededObjective MetObjective 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/ExamplesObjective ExceededObjective MetObjective 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/ExamplesObjective ExceededObjective MetObjective 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/ExamplesObjective ExceededObjective MetObjective 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/ExamplesObjective ExceededObjective MetObjective 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/ExamplesObjective ExceededObjective MetObjective 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/ExamplesObjective ExceededObjective MetObjective 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/ExamplesObjective ExceededObjective MetObjective 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 ExceededObjective MetObjective Not MetSome 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. ................
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