If your organization is like most, you’ve been hearing a lot about Meaningful Use but your department has been mostly on the periphery … until now. The overall goal of Meaningful Use is to promote the spread of electronic health records to improve healthcare in the United States. The government program is being rolled out in stages and most organizations are currently in Stage 1 or headed into Stage 2...
The program has carried significant financial incentives for hospitals (and providers). However, as the program moves to future stages the financial incentives will be replaced with financial penalties for organizations that have chosen not to participate and/or that do not meet the requirements.
Until now – most of the thousands of data elements (with the exception of perhaps two elements: anesthesia type and timestamps) have all come from non-OR specific systems. However, with the roll out of the 2014 Quality Measures (which all organizations, regardless of Stage, must report on) there are now six quality measures that require perioperative data collection (from both nursing and anesthesia documentation).
Deciphering the data logic for these measures and getting meaningful data out of your perioperative EHR can be (and likely will be) a challenge. Resources are available. Two key resources that we highly recommend reviewing are:
Additionally, please refer to the "where to start" section of this article for additional tips and information.
|Anes Type, Start & Stop D/T||X||X||X||X|
|Device Type, D/T Applied||X||X||X||X|
|Medication, Admin D/T, Route||X||X||X|
|Patient Expired Intra-operatively||X||X|
|Physical Finding, Urinary Diversion||X|
|Procedure Type, Start & Stop D/T||X||X||X||X|
|Urinary Catheter Type, D/T
Here are some examples of data elements and codification required from each of these categories.
|Device Applied||SNOMEDCT||Indwelling urinary catheter||SCIP 9|
|Compression stockings, intermittent pneumatic compression||VTE 1 & 2|
|Pacemaker||SCIP 1 & 2
|Suprapubic Catheter||SCIP 9
|RxNorm||Antibiotics||SCIP 1 & 2|
|VTE Prophylactics-Heparin, Low Molecular Weight Heparin, Warfarin||VTE 1 & 2|
|General or Neuraxial Anesthesia||SCIP2, 9,
VTE 1 & 2
Other Cardiac Surgeries
Hip or Knee Arthroplasty
Abdominal or Vaginal Hysterectomy
|SCIP 1, 2, 9|
|SCIP 1 & 2
Capturing the data that excludes a patient from eligibility (“exclusions” above) for the quality measure is just as important as data which includes the patient. Not capturing exclusions can result in lower performance rates and subsequently, potential financial penalties.
Example: SCIP-INF1 Antibiotic within 1 hour of Incision
|10/01/2013||6:45 AM||Patient Admitted to Hospital|
|10/01/2013||8:15 AM||Anesthesia administers IV Cefazolin 250mg/ml RxNorm 562062|
|10/01/2013||8:45 AM||INCISION - Intraop Procedure Performed:
Arthroplasty of knee using cement Snomed 307817008
Quality Measure Denominator = Procedure, Performed: CABG, or Other Cardiac, or Hip arthroplasty, or Knee arthroplasty, or Colon surgery, or Abdominal hysterectomy, or Vaginal hysterectomy, or Vascular surgery
Quality Measure Numerator = Medication, Administered: IV Antimicrobial Medication starts < = 60 minutes before Incision, or SCIP IV quinolone starts < = 120 minutes before Incision, or IV Vancomycin starts < = 120 minutes before incision
Procedure, Performed: Knee arthroplasty coded with Snomed code 307817008 has an Incision Date/Time of 10/1/13 at 8:45am
Medication Administered: Cefazolin coded with RxNorm code 562062 is administered at 8:15am which is < = 60 minutes before Incision Date/Time
Patient meets Clinical Quality Measures SCIP-INF1
Getting started can be daunting and like most projects, taking a team approach works best. Key players to involve on the team include perioperative leadership, anesthesia and surgical IT system administrators, hospital quality and/or meaningful use project manager, and pharmacy technician.
Recommended steps for the team include:
Contact us using the form below and/or feel free to give us a call 423.753.0054.