Hospital Outpatient Quality Reporting Program

Transcription

1 Taking the Mis Out of Mismatch: Top 10 Mismatched Data Elements from Q through Q Questions & Answers April 17, :00 a.m. ET Moderator: Susan Easter, MS Educational Coordinator, Hospital OQR Program SC Speaker: Laurie Ciannamea, MBA Project Coordinator, FMQAI Question 1: I have a question regarding OP-20, the Provider Contact Time. Our ER physicians with critical patients do see them very frequently on arrival. And on the ED documentation sheet it says "Physician initial contact." So, will that suffice as saying that they were seen on arrival? Answer 1: Hi, this is Marty Ball. That would be fine to describe arrival time but, since they say arrival time, there needs to be supporting documentation with that, such as an exam, a timed exam, to show that they actually saw the patient on arrival. Question 1: Okay. If the nurses documented "physician in on arrival, examination done," does that suffice? Answer 1: Yes. Question 1: Okay. All right. Thank you. Page 1 of 19

2 Question 2: The attachment at the the resource at the end of the presentation shows the one that's dated January 1, 2012, that it's observation just within the ER. I thought that changed in January of this year. Is that still just if it's in ER? The observation status? Answer 2: Lesley, can you take that, please? Answer 2: Yeah. I think that's for first quarter We're still working on the third and fourth quarter. So, we actually would have to yeah, it still. Answer 2: This is Kari. I can answer that. Observation services for 20 January 2013 did change. Any order any physician order that's written in the on the ED record, if it's his observation, it doesn't the observation doesn't have to be limited to the to receiving it to the patient being placed in observation and receiving services in the ED. That can be anywhere. As long as there's an order, a physician order, you would say yes to observation services. Question 2: Okay, thank you. Question 3: Yes. I have a question about chest pain and exclusions. It was my understanding that if the differential diagnosis included MI, that trumped things like musculoskeletal if they were both included. And the second part of the question is I had actually ed this question previously and my other question is that our Wellsoft record does not say AMI in the differential diagnosis, it says MI, and that's an ED record. Does this have to have the A before? Because that's basically what the answer I got was when I questioned it. Page 2 of 19

3 Answer 3: This is Kari. And yes, it has to have acute or evolving myocardial infarction or AMI. An MI would not be would not trump it without the descriptor of it being acute or evolving. Question 3: So, in the differential diagnosis, if we add the A to AMI then that does in the differential diagnosis see, because the way ours is written, there's multiple things in that differential diagnosis, and it goes from acute MI well, I'm saying acute because they're coming into an ED. But, it goes from the differential diagnosis being an MI or other things including musculoskeletal, which is an exclusionary term. So, that was my question. So, if we change that differential diagnosis to say AMI instead of just MI, then that is included, correct? Answer 3: That's correct. Then it would be included, even though there was an exclusion term also documented. But, that's the only thing that would trump it to make it a yes for probable cardiac chest pain. Question 3: Right. All right, thanks. Question 4: Yes, thank you. My question has to do with time left ED. We have right on our ED records that it says "time left ED," say 11:00. But, the nurse writes that the patient is discharged with instructions at 11:10 when she creates the note. Are you supposed to take the 11:10 or the actual time left the ED that's documented on every record? Answer 4: Per the Specifications Manual, if you have two discharge times that both have information in them that can prove the discharge, you would take the later time. So, if you had such as your standard printed on your sounds like your electronic medical records (inaudible) and then the nurse Page 3 of 19

4 documents 11:20 patient discharge with printed instructions, you would choose the later time. Question 4: Okay. And one other thing. For a first provider in room or first provider first contact time, we changed our verbiage to be, again on the electronic record, for first provider in room. Is that acceptable? Answer 4: This is Toni. Yes, that would be acceptable. Question 4: Okay, thank you. Question 5: Hi. Yes, my question's about arrival time, the data element arrival time. On our face sheet in the ED, they not only have the patient information, but, in the lower right-hand corner they have a patient data block that has the patient's name and account number and date of birth, etc. But it also has a line in there that says "admit date and time" and that's the time the system time from registration. So, because it says "admit date and time," does that make it a time that can be abstracted, or is that considered an addressograph? Answer 5: No, that's considered an acceptable time when it's on the registration sheet. The difference we made with CDAC was when there's no label on that time, then it can be non-included time. Question 5: Okay. So, as long as it says the words "admit date and time " Answer 5: Right. Question 5: Okay. Page 4 of 19

5 Answer 5: And if that's the first contact with the patient, then that's very acceptable. Question 5: Okay. Can I ask you one more quick question? Answer 5: Sure. Question 5: If the five minute variance is that for inpatient as well as outpatient, do you know? I know this is outpatient questions, but Answer 5: Outpatient or (Multiple speakers.) Answer 5: I'm confirming that that applies to both the IQR and the OQR program. Question 5: Okay. Thank you so much. Question 6: Our registration history form says "date registered" and "time registered." So, my question is, would that be acceptable as an ED arrival time? Answer 6: This is Laurie. Yes, it would be if it's the earliest time that the patient's known to be in the ED. Question 6: Thank you. Question 7: Good morning. I've got kind of a similar question that the first caller had, and I'm wording it a little differently. If this is on the initial contact time by the physician if the time documented is the actual arrival time, will that pass? Like, say somebody comes in per ambulance and you they're timed in at 13:52, and the doctor's, like, right there at the door if the nurse Page 5 of 19

6 or the physician, whomever, writes that the physician saw the patient at 13:52, will that pass? Answer 7: This is Toni. There would need to be an exam or some type of documentation to reflect the contact to go along with that documentation. Question 8: I'm got two. One of them goes along with that same thing because, on the T-sheet, my physicians will mark "on arrival," as the lady just spoke, and then they fill out the T-sheet, which gives you the exam. And the nurse is documenting "patient arrives by ambulance to trauma one at 15 13:52, starts describing the patient's condition and the physician's intubating or whatever. So, would that count? Because you've got the nurse documenting the time and the physician has documented "on arrival" and he's filled out that T-sheet with an exam. Because you're saying two different things. You're saying if he marks "on arrival," then he has to also say a time and support his exam. Well, his T-sheet is his exam. And then the nurse is not saying "doctor at the bedside." She's starting a note that says all the things that we as nurses do and then, say the physician is giving an order, the physician is doing this. She's not specifically saying he's at the bedside at that moment, but in those notes she's describing what he's ordering and doing. Is that going to pass for validation? Answer 8: This is Lesley. If we can tell this is from CDAC if we can tell that there's actual contact with the patient, we would probably take that. And this is without seeing the documentation in what you're saying but, by what you're saying, it sounds like we could put that physician in with the patient. We would probably pick that up. Question 8: And just ask a question. May I highlight I know you guys don't recommend it, but we and I know there are many facilities that probably Page 6 of 19

7 have the same issue because I heard a lot of this discussion about we need to adjust our electronic records so that your people that are reviewing our records can have an easier time of abstracting and we don't get as many mismatches. But, we don't have control over our vendors and how they format things. And trust me; I understand what they look like because I've put these together personally before they go out the door so that you have as much information as you need. And so, a single source documentation can be hard to get sometimes from the way they print, from the way we document. They're single source when we put them together, but when they print as a paper document, a lot of times they don't come that way. So, I may see my single source on one page that would be acceptable, say, on an ER nurse's note section were the nurse's initial is. It's not really her signature, but I attach the signature page to the back to prove that that is her signature with the IV antibiotic time, route, date, and all that on it. But, you may be looking for a MAR. And are you understanding what I'm saying? So, you're you may mismatch me for saying that I gave you a date and time where your individuals may be looking for something more familiar in the paper world. So, is it okay for me to highlight where I got my single source from? Answer 8: Our abstractors are instructed not to automatically accept highlighted information. Question 8: I know. Answer 8: They have to use the record and make a determination if it appears that it I mean, I don't do OSI, but Trudy's here, so let me let her answer that one. Page 7 of 19

8 Answer 8: Well, as far as trying to be counted as a single source, it would have to be clear. And like Lesley said, we really we do tell our abstractors to really ignore anything that's highlighted. And if it would be the most accurate information, they can pick it, but not to assume it's accurate. Answer 8: Keep in mind, too, that a single source could be three pages of an anesthesia record or a surgical record. Answer 8: Right. That is correct. We may have several pages of an anesthesia record and, if we can determine all those pages go together, we consider that a single source. Question 9: Hello. Our ED physicians use also a T-sheet, and what they do is there's a statement at the top that just says "time seen," but they use, like, a stamper, either electronic or a hand-stamper kind of right above that or on the side of the T-sheet to reflect the time that they're going in to see the patient, then they complete it. So, would that stamper, electronic stamp, would that be acceptable on a paper document for time seen? Answer 9: If it's actually, the people at the T-sheet corporation were nice enough to change their papers to include initial provider contact on the T-sheet at the top as opposed to what it said a couple of years ago. It was just time last year; it was just time. So, if it's a time stamp up there for initial provider contact, that's fine on the T-sheet, if I'm following that. Question 9: Right. So, even though it's not in, like, the box right next to the time seen, it may be at the very top or kind of on the side. If it's on the top of that page somewhere, is that enough to reflect that that's the time and date? Page 8 of 19

9 Answer 9: Well, it has to show that that's when the physician did the exam. So, on the slide example, "time patient care initiated by licensed independent provider " I don't know if on the far right-hand side you had a time stamp, I don't know that the CDAC, if they would accept that. Answer 9: Yeah. If we know it's physician, we would take it. Question 9: Okay. Question 10: Yeah, I think I just need clarification on a couple of things we've already talked about. On that T-sheet example, when you were talking about it earlier, you said something about on arrival was not acceptable. Are you talking about just checking the box as opposed to putting a time in that slot? Answer 10: Right. Just checking the box, you would need other documentation on there to show that it was actually, like, a timed exam because what they're Question 10: So, he'd need the time in there. Answer 10: Right. Answer 10: Right. Question 10: Another question on arrival and I'm losing my notes. I think about slide 24, on mismatch number four, you listed about three things that were could not could cause a mismatch; preprints, addressograph, and something else. I didn't get that, and I wanted to make sure I had it. Answer 10: You shouldn't use preprinted forms, time stamps, or addressographs. They're all exclusionary. Page 9 of 19

10 Question 10: Time stamps are exclusionary. Okay. Doesn't that contradict what we just told the last question person? Answer 10: Well, I think on the last what they were talking about was on the T-sheet. They said that if they knew the physician was time stamped at that time with the T-sheet. What I think what we're talking about more time stamps is when there's like the addressographs when you would in the old days maybe the old chart would be stamped up at the same time, and that's what I think we're referring to when we say time stamps. Question 10: Okay. So then the electronic record that we use in particular, that just says "the patient arrived at" and then later on down there it's got "physical exam time," is all okay because it's coming out of the computer and it's electronic, but it's current. Answer 10: Right. That's fine. Answer 10: Right. Answer 10: That's what we're looking for. Answer 10: The time stamp refers to the basically, like Marty said, the old fashioned time stamp that was on every page. Question 10: Okay. Okay, I think that's all for me. Thank you. Question 11: Hi. Yes, I have a question about observation service. I know we've gone through that already. This one's a little bit different. If there is no Page 10 of 19

11 observation unit and you have an order that says observation, how do we answer observation services? Answer 11: You will answer it yes. This is Kari. If there's an order, if it's on the ED record, you'll answer yes. Question 11: Without an observation unit. Answer 11: Right. Correct. Question 11: Thank you. Answer 11: Okay. Question 12: Yes, good morning. Back to the probable cardiac testing chest pain question. I recently had a patient who came in with atypical chest pain. We kept him in Obs and stressed him the next morning. The physician then documented that the patient had acute coronary syndrome, and we sent them up to be cathed. But, it's my understanding then, because of the atypical and it did not say AMI, that I am to answer no to probable cardiac chest pain. Is that correct? Answer 12: Yes. If there's a documented exclusion like atypical chest pain, you would answer no to probable cardiac chest pain. Question 12: Okay. Thank you very much. Answer 12: Okay. Page 11 of 19

12 Question 13: Oh, hi. I have another question about time of arrival. If we have a place on the chart that states "time seen by physician" and he handwrites in "on arrival" and that's followed by his handwritten exam, is that acceptable to use the arrival time or does he have to actually put like 11:32 in there? Answer 13: This is Toni. There would need to be the exam would need to be timed as well. Question 13: Okay. Okay, and I have one more question. Is there a way to change who in our facility receives the request for the records from CDAC? Answer 13: Yeah, you can go and give us a call here, and we can make that change in the PRS database for who is your medical record contact. Question 13: Okay. We call. Answer 13: Call the? Question 13: Okay. Answer 13: Support contract. Question 13: Okay. Okay, thank you. Question 14: Yes, hello. We have a couple of questions, one of them being back to the ECG interpretation. We wanted to see what you all are expecting as far as when you have an EMS strip and the doctor uses that for documentation of interpretation. What do you expect him to have documented to tie it to that strip? Page 12 of 19

13 Answer 14: This is Lesley. He needs to reference that EMS EKG; he has to say that, EMS EKG or something that directs us to know that he is talking about that one. Question 14: So, it does need to specifically say EMS? Answer 14: He could say initial EKG done in EMS or something like that so we know that he's referring to the EKG done in the ambulance. Question 14: Okay. All right. Then we have some questions on arrival time here. You want to do? Question 15: Yes. May name's Deborah Donahue, and my question is it looks like some of the documents need to specifically say arrival time, but if we use labs or x-rays, they don't say arrival time, but it does infer the contact it does say we've had contact with the patient. So, I'm wondering about the lab, x- ray, ECGs. Those seem like generic times to me because they don't say arrival times, but tell me your interpretation. Answer 15: No, those times are acceptable for arrival time. Arrival time's just trying to think about it when the patient first physically arrives to the ED. So, if a patient comes through the ED doors complaining of chest pain and the first thing that happens is the triage nurse takes him back and gets an EKG, then that's very acceptable. If the patient comes in and there's a tech out in the waiting room that's doing a lab draw on patients with fevers or whatever protocol they have, then that's acceptable. Question 15: The reason I'm wondering is because, on depart time, we have to have that particular lingo, some kind of departure, transfer, left. And anything documented after that depart time becomes a UTD. Page 13 of 19

14 Answer 15: Being that, again, you're looking for when the patient was physically last in the emergency room. That's why we're looking for specific lingo on that. Question 15: What we struggle with is, like, the face sheet cannot be used because it doesn't say explicitly arrival time, but then the lab and x-ray and those other sources can be used, but they don't say that either. Answer 15: Well, the reason for that, what happened was because some smaller hospitals would pre-register people. If they're coming in the ambulance might call the registration clerk and say I'm bringing in Joe Smith, and he was there last night, and they would type up the registration real quick. And so the registration might be 15 minutes before Joe Smith got there. So, I said, well, to eliminate that, or one of the ways we could eliminate that, is just to take the time off, or label the time preregistration as a nondescript preregistration, which would be fine. Then they wouldn't take that as the registration time. Is that clear? Question 16: Hi. I have a question regarding the ED discharge time, the departure time. We utilize Meditech for our documentation, and we have a section that has when they came in through the ER, the time, and then the time that they left. And that I'll give you an example, like 10:51 the patient was in the emergency room to 13:20. But we also have a section that is specifically for ED. They have their own documentation. And one of the fields that they fill out is the departure date and time. So, for the same patient they have that the patient departed at 14:22. So, would you utilize the 14:22, or would you use that one that says 13:20? Page 14 of 19

15 Answer 16: You would want to use when the patient physically left the emergency room. So, if you have a patient departed at 14:22 and that would be the latest time, then that would be an acceptable time. Question 16: Okay. Answer 16: The problem with the EHRs is that they'll get into you'll find three or four different times that show that the patient left, and there'll be times that are such as off the tracking board or the physician will write disposition and a time. And so, you'll get into a lot of different times that can really muddy the waters. So, that's why we really want to try and make it where the patient physically left, to capture the latest time that the patient was there, so we don't pull up a time that's an hour later when the patient went off the tracking board and obscure your in and out ER times. Question 17: Hi. I have a question regarding your time stamp. Just to further clarify, I understand the addressograph concept, but, regarding the time stamp, we also have, like, a manual clock where the patient would handwrite the chief complaint in the emergency department and write that time and the date that they arrived. But then the volunteer or somebody would actually take that piece of paper and clock it in. It's not an addressograph, and it has the actual date and the time. Answer 17: Right, and that's acceptable. Answer 17: Yeah. If the patient's writing in the time that they arrived, which is what I'm understanding from what you're saying, that's an acceptable time. Answer 17: Or if they do go to a machine and they do a time stamp. So, the time stamp comment was in regards to something that's going to be on possibly all Page 15 of 19

16 the pages of the record that is not a specific time stamp to a process that happened right at that time. Question 17: Okay. I just wanted to clarify that. Then we have another question. Question 17: Yeah, we have a question regarding provider contact time. So, my understanding is I'll give you an example. I have an event log which logs in "seen by provider" and a time. And then I have under the orders a statement that says "RME was completed at this time" and another date and time with the physician's signature. Which one would I use? Can I use the "seen by provider," or do I need to use the one that shows that the RME was completed? They're about a half an hour different. Answer 17: You can use the "seen by provider" time. Question 17: I can use that? Okay, perfect. Thank you. Question 18: Hi. My question also has to do with when the provider initially sees the patient. And on our physician portion of our electronic medical record we have a statement that says "patient medically screened," and there's a time associated with that. Are we okay using that time if that's the first time that there's been any contact? Answer 18: Yes, that would be acceptable. Question 18: Okay. Thank you. Question 19: Hi, it's Gay. My question is on slide 33, the probable cardiac chest pain. I couldn't really understand what she was saying about which trumps which. Do the inclusion terms trump the exclusion terms or vice versa? Page 16 of 19

17 Answer 19: Generally, the exclusion term trumps the inclusion term. If there's an exclusion, you would select no for probable cardiac chest pain. If the only exception is if there's a differential diagnosis of acute myocardial infarction. And it has to have the descriptor that it is acute; then you would select yes, even if there's an exclusion. Question 19: Thank you. Question 20: Hi. I just want clarification on the EKG date and time. The data element says take the EKG closest to arrival time. Let's say the EMS took it 20 minutes before arrival, and the ED took it eight minutes after arrival. We were taking the eight minutes, the one after, but should we be taking the EMS one? Are you saying that anything taken in the EMS within 60 minutes of arrival is actually trumps anything else because it can be entered in as zero? Answer 20: This is Kari. Yeah. For ECG, ECG date, and ECG time, if there are if there's an ECG done in the ambulance and it's done within 60 minutes, you take that one first, even if it's not the closest to arrival. For initial ECG interpretation, which is for a different measure set, you would take the closest to arrival. But, for the data elements ECG, ECG date, and ECG time, which are which only apply to OP-5, Median Time to ECG those, if it's if the ECG was done in an ambulance or within one hour prior to arrival, that's the one you'd use, even if it's not as close to arrival as the one that was done in the ED. Does that make sense? Question 20: Okay. Yes, it does. Answer 20: Okay. Page 17 of 19

18 Question 20: So, the initial interpretation does not have to be the first the EKG date and time one that you're making reference to the initial interpretation does not have to be that one, correct? Answer 20: That's right. There are different measures, there are different data elements, and you could use different tracings for them. Question 20: Okay. Answer 20: Yes. Question 20: All right. Well, thank you. Susan Easter: Okay. And that was our last question for today. We're out of time, I'm afraid. So, if we did not get to your question, please use the question-andanswer tool located on QualityNet.org to send it to the HOQR staff for a timely response. I'd like to thank our presenters and participants for the valuable information and questions you provided. We hope you've heard some useful tips and practices that can be implemented to make improvements in your abstracting and data reporting to the Hospital Outpatient Quality Reporting Program Measures. As a reminder, there will be a short survey sent to you via . Please take a few moments to complete this and provide us with your valuable feedback. We do listen and have incorporated your suggestions from past surveys to enhance our educational programming. Page 18 of 19

19 Our next webinar will be held on May 15 th at 10:00 and 2:00 Eastern Time on the CART Tool. Registration announcements will be sent via the ListServe, so please be sure that you have signed up on the QualityNet ListServe if you have not yet done so. You can reach this page at and then click on notifications. Thank you for taking time from your busy day to join us. Please enjoy the rest of your day. END This material was prepared by FMQAI, the Support Center for the Hospital Outpatient Quality Reporting program, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). The contents presented do not necessarily reflect CMS policy. FL-10SOW-2013FS4T Page 19 of 19