EPRP Update

1. EPRP Update 2QFY2013 WVMI Confidential and Proprietary

2. OBJECTIVES • This presentation will provide information about changes to EPRP instruments for 2QFY2013 • You will also be provided information on some changes to the CRC Overuse Colonoscopy and FOBT instruments • It is important that you review highlighted changes in the instruments in conjunction with this presentation • Please ask questions if you need clarification WVMI Confidential and Proprietary

3. CGPI WVMI Confidential and Proprietary

4. PI Module Changes • An exclusion has been added to the definition/decision rules of question 21 (tobnow) • A patient who uses electronic cigarettes (ecigarettes) only would not be considered a current tobacco user • If there is no documentation of tobacco use and only documentation of use of electronic cigarettes in the applicable timeframe, answer “no” to the question above • The same exclusion applies to question 22 (tobuseyr) WVMI Confidential and Proprietary

5. Shared Module Change • The definition/decision rules of question 66 (chgbprx) have been revised to provide clarification when the change is discontinuation of an anti-hypertensive medication • If the ONLY anti-hypertensive medication change is discontinuation of a medication, select “2” (no). • If the daily dose of an anti-hypertensive medication was changed, select “1” (yes). WVMI Confidential and Proprietary

6. Validation Module • There are changes to the discharge status question (dcdispo) in the CGPI Validation Module to provide consistency with The Joint Commission question • The changes will be discussed with inpatient instruments • There are no changes to CGPI scoring WVMI Confidential and Proprietary

7. HBPC Changes • The only changes in HBPC are format changes • The answer options (yes/no) were added under the question text for consistency in three questions • There are no changes to HBPC scoring WVMI Confidential and Proprietary

8. TBI Changes • The only changes in TBI are format changes • The answer options (yes/no) were added under the question text for consistency in several questions • There are no changes to TBI scoring WVMI Confidential and Proprietary

9. Inpatient Instruments WVMI Confidential and Proprietary

10. Discharge Disposition • The discharge disposition question (dcdispo) in ACS, IHF, PN, SC, GM, and CGPI has some changes/clarifications • 1. Home • ALFs include assisted living care at nursing home/facility • Home includes retirement facilities • 2. Hospice-Home includes home settings as listed in #1 (Home) WVMI Confidential and Proprietary

11. Dcdispo • If there is documentation that further clarifies the level of care to which the patient was discharged, that documentation should be used to determine the correct value to abstract. • If documentation is contradictory, use the latest documentation. • If documentation is contradictory, and you are unable to determine the latest documentation, select the disposition ranked highest (top to bottom) in the following list. • Acute Care Facility • Hospice – Health Care Facility • Hospice – Home • Other Health Care Facility • Home WVMI Confidential and Proprietary

12. More dcdispo rules • Values “2” (hospice-home) and “3” (hospice-Health Care Facility) includes discharges with hospice referrals and evaluations • If the medical record identifies the facility the patient is being discharged to by name only (e.g., Park Meadows) and does not reflect the type of facility of level of care, select “5”. • If the medical record states only that the patient is being discharged and does not address the place or setting to which the patient was discharged, select “1”. WVMI Confidential and Proprietary

13. dcdispo rules- AMA • Please review the changes to the rules for selecting option 7, Left Against Medical Advice/AMA • Explicit “left against medical advice” documentation is not required • e.g Record documents “patient refusing to stay for continued care” is acceptable to select option 7 • For the purposes of this data element, a signed AMA form is not required. • If any source states the patient left against medical advice, select value “7”, regardless of whether the AMA documentation was written last. • Documentation suggesting that the patient left before discharge instructions could be given without “left AMA” documentation does not count. WVMI Confidential and Proprietary

14. dcdispo • Excluded Data Sources (do not use to determine discharge disposition) • Any documentation prior to the last two days of hospitalization • Coding documents WVMI Confidential and Proprietary

15. Comfort • There are some changes to the comfort measures only question (PN, IHF, ACS) • A definition of comfort measures only has been added: • refers to medical treatment of a dying person where the natural dying process is permitted to occur while assuring maximum comfort. It includes attention to the psychological and spiritual needs of the patient and support for both the dying patient and the patient’s family. Comfort Measures Only is commonly referred to as “comfort care” by the general public. It is not equivalent to a physician order to withhold emergency resuscitative measures such as Do Not Resuscitate (DNR). WVMI Confidential and Proprietary

16. Comfort Changes • Documentation of “CMO” should be disregarded if it is clear that it is not being used as an acronym for comfort measures only • Example: “History of CMO-dilated” in the context of cardiomyopathy • Disregard documentation of an inclusion term when • Comfort measures is made conditional upon whether or not the patient arrests. (Examples: “DNRCCA” (Do Not Resuscitate-Comfort Care Arrest; “Comfort Care Protocol will be implemented in the event of a cardiac or respiratory arrest”; “Family requests comfort measures only should the patient arrest.”) WVMI Confidential and Proprietary

17. Comfort Changes • Disregard documentation of an inclusion term on a pre-printed form signed by a physician, APN, or PA when • an Inclusion term in a statement that is not part of the order or that is not clearly selected (on a form that offers options to select from). Examples: • Inclusion term used only in the title of the form (e.g.,DNR-Comfort Care order form - option “Comfort Care” is not checked.) • Inclusion term used only in the pre-printed instruction for completing the form (e.g., “Copy of form to hospice”, “Instructions” section of the form further defines the option “Comfort care”) WVMI Confidential and Proprietary

18. Pneumonia WVMI Confidential and Proprietary

19. PN Changes • Validation module has changes to comfort and dcdispo as previously described • Acute Care module changes: • A condition has been added that causes a “yes” answer to compcond (compromising condition) • Physician/APN/PA documentation within 24 hours after hospital arrival that the patient has a “prolonged” QT interval (QTc). • There is a wording change to the D/D rules for ptallerg for consistency with Joint Commission changes • If the record documents an allergy, sensitivity, or intolerance to beta-lactam/penicillin or cephalosporin antibiotics, enter “1”. WVMI Confidential and Proprietary

20. PN Scoring and Exit Report • 2Q scoring algorithms include discharges >=1/1/2013 • No other changes to PN scoring or exit report format WVMI Confidential and Proprietary

21. IHF WVMI Confidential and Proprietary

22. IHF Changes • IHF has changes to comfort and dcdispo as previously described • Please review TJC Table 2.6, Appendix H of qualifiers and modifiers (exclusions), which has some changes. • This table is found in several questions: q23 (lvfless),q28 (narlvsf), q36 (contace3), q38 contrarb1, q44 noacewhy, q47 noarbdc, and q50 nobbatdc • The insulin discharge instruction questions have been removed from the IHF instrument WVMI Confidential and Proprietary

23. IHF Scoring • dmi1 has been removed from the Pilot Exit report • 2Q scoring algorithms include discharges >=1/1/2013 • No other changes to IHF scoring or exit report format WVMI Confidential and Proprietary

24. ACS WVMI Confidential and Proprietary

25. ACS Validation • Q6 (aprocode): A hard edit has been added to the software • If amiprin=1, the principal diagnosis code must be 410.x1 or 410.x0 • Changes to dcdispo and comfort as noted earlier WVMI Confidential and Proprietary

26. Initial Presentation Module • Please review the revisions to q8 (intrpecg) • There is additional guidance for identifying the ECG interpretation to use in answering intrpecg • Identify the ECG performed closest to arrival, either before or after hospital arrival, but not more than 1 hour prior to arrival. Must be prior to any procedures (cardiac cath or PCI)and not longer than 24 hours after arrival. • Exception: If the pre-arrival ECG and the first ECG performed after arrival are exactly the same amount of time away from hospital arrival (e.g. both ECGs are 10 minutes away from Arrival Time), use the first ECG performed after hospital arrival. WVMI Confidential and Proprietary

27. intrpecg • There are some changes to the ST segment elevation exclusions • old, chronic, previously seen, unchanged, no new changes, no acute changes, no significant changes when compared to a prior ECG. EXCEPTION: When the ST-elevation on the ECG done closest to arrival is described as previously seen on an ECG done by EMS or physician office prior to arrival, this ST-elevation may count as an Inclusion • There are changes to TJC Table 2.6, Appendix H, Qualifers/Modifiers WVMI Confidential and Proprietary

28. NSTEMI Clarification • NSTEMI: (non-ST-segment elevation myocardial infarction, non-ST elevation MI) must be clearly documented by a physician/APN/PA in association with the initial ECG findings.  • For example, ECG may show T wave inversion and physician notes under impression: “NSTEMI”.  WVMI Confidential and Proprietary

29. ACS Revascularization Module • The definition and decision rules for fibdelay and pcidelay have been revised • There are some changes to the inclusion guidelines for exceptions that do not require documentation that a delay occurred • Mechanical circulatory assist devices • Aortic balloon pump • Biventricular assist device (BiVAD) • Intra-aortic balloon (IAB) • Intra-aortic balloon counterpulsation (IABC) • Intra-aortic balloon pump (IABP) • Intra-aortic counterpulsation (IAC) • Intra-aortic counterpulsation balloon pump (IACBP) • Left ventricular assistive device (LVAD) • Percutaneous ventricular assist device (PVAD) • Ventricular assist device (VAD) WVMI Confidential and Proprietary

30. Fibdelay and pcidelay • Suggested Data Sources for documentation of a reason for delay (Physician/APN/PA documentation only): • Code sheet (if signed by physician/APN/PA) • Consultation notes • Discharge summary • Emergency department record • History and physical • Operative notes • Physician orders • Procedure notes • Progress notes • Excluded Data Sources: • Any documentation dated/timed after discharge, except discharge summary • operative/procedure/diagnostic test reports (from procedure done during hospital stay). WVMI Confidential and Proprietary

31. ACS Continuing Care Module • q9 (lvfdoc2) The timeframe for looking back for an assessment of left ventricular systolic function (LVSF)/ejection fraction (EF) has been changed to 5 years. • You will enter the most recent assessment found in the 5 year period • Review TJC Table 2.6 of negative qualifiers and modifiers (exclusions) WVMI Confidential and Proprietary

32. ACS Discharge Module • Please note the changes to TJC Table 2.6 of negative qualifiers and modifiers (exclusions) in q2 (noacewhy), q4 (acsnoarb), q11 (nodcbb) WVMI Confidential and Proprietary

33. ACS Scoring • 2Q scoring algorithms include discharges >=1/1/2013 • No other changes to ACS scoring or exit report format WVMI Confidential and Proprietary

34. Surgical Care WVMI Confidential and Proprietary

35. Definition/Decision Rule Changes • Total intravenous anesthesia (TIVA) has been added to the inclusion list for general anesthesia in q18 (anestype) • There is a change to the rules of q30 (allerbio) • If the record documents an allergy, sensitivity, or intolerance to beta-lactam/penicillin or cephalosporin antibiotics, enter “1” (yes). WVMI Confidential and Proprietary

36. Reason for not removing the urinary catheter postoperatively on POD 1 or POD 2 • There is a change to answer option 1, q45 (reascath1) • 1. Documentation that the patient was in the intensive care unit (ICU) and receiving one or more of the listed medications (diuretic, vasopressor/inotropic, or paralytic therapy) • Refer to Joint Commission, Appendix C: • Table 3.13 for a list of diuretics • Table 3.14 for a list of inotropic and vasopressor agents • Table 3.15 for a list of paralytic agents • Value “1” does not require physician/APN/PA documentation. WVMI Confidential and Proprietary

37. Changes to D/D Rules for preadmbb (BB prior to admission) • Please review the rule changes to q50 • If the patient was transferred from a facility where they were started on a beta-blocker as a daily medication, select “1”. • If the beta-blocker is listed as a daily “home” or “current” medication and the physician/APN/PA documents to discontinue or hold the beta-blocker before surgery WITHOUT a documented reason for not administering, select “1”. • If the beta-blocker is listed as a daily “home” or “current” medication and the physician/APN/PA documents to discontinue or hold the beta-blocker before surgery WITH a documented reason for not administering, select “2”. WVMI Confidential and Proprietary

38. Changes to D/D Rules for preadmbb (BB prior to admission) • More rule changes to q50 • The use of hypotension or bradycardia as a reason must be substantiated by documentation that the blood pressure was <= 100 mmHg or that the heart rate was less than 50 bpm respectively. • Specific documentation that a beta-blocker was/was not a daily home medication takes priority over a checklist (e.g., Preoperative nursing note includes a beta-blocker on home medication list and checklist on anesthesia form indicates beta-blocker as “no”; select “1”. • When conflicting documentation exists concerning whether the beta-blocker was being taken on a daily basis or if the patient stopped taking it at home, there must be clear documentation that the beta-blocker was not being taken daily or had been stopped in order to select “2”. Documentation that the patient missed one dose or did not take the beta-blocker the day prior to arrival is not sufficient to select “2”. WVMI Confidential and Proprietary

39. Changes to D/D Rules for preadmbb (BB prior to admission) • Suggested data sources for determining if the patient was on daily beta blocker therapy prior to arrival • admitting notes • anesthesia records • consultation notes • medication reconciliation form • history and physical • nursing admission assessment • preoperative record • progress notes WVMI Confidential and Proprietary

40. BB On the Day of Surgery • There is clarification added to the rules of q52 bbpreor (Did the patient receive a beta-blocker on the day prior to surgery or the day of surgery?) • Day of surgery includes documentation a beta-blocker was administered before, during, or after surgery on the day of surgery (same calendar day). WVMI Confidential and Proprietary

41. Reasons for No BB • Please review the updates to the rules for q53 (reason for not administering BB on the day prior to surgery or the day of surgery) and q55 (reason for not administering a BB on POD1 or POD2) • There must be a reason documented for each day the beta-blocker is held or not administered in order to select the corresponding value. • Patient refusal does not have to be documented by a physician/APN/PA, but must be documented in timeframe corresponding to applicable value. WVMI Confidential and Proprietary

42. Reasons for Not Administering BB • More rule changes for q53 and q55 • In order to consider documentation of bradycardia, hypotension or concurrent use of intravenous inotropic medications during perioperative period as a reason for not administering a beta-blocker, the following is required: • A documented systolic blood pressure of less than 100 mm/Hg and/or a heart rate less than 50 bpm during the time period represented in the value being abstracted, is sufficient to select that value. • Vital signs obtained while patient is on cardiopulmonary bypass machine or while being removed from bypass cannot be used to determine bradycardia. • Documentation of bradycardia or hypotension as a reason must be substantiated by documentation of a heart rate of less than 50 bpm or systolic blood pressure <= 100 mm/Hg respectively during the timeframe for the applicable value. WVMI Confidential and Proprietary

43. Reasons for Not Administering BB • Clarification re: holding BB due to vital signs • If the physician writes an order to hold the beta-blocker when the patient’s vital signs are outside certain parameters and there is documentation that the beta blocker was held because the vital signs were outside the parameters during the period specified in the allowable value(s), select the appropriate value(s). • The vital signs to support this documentation are required and must be documented as present during the timeframe for the applicable value(s). WVMI Confidential and Proprietary

44. Reasons for Not Administering BB • Suggested data sources for reasons for not administering BBs • consultation notes • history and physical • medication administration record • nursing notes • physician orders • progress notes • vital signs record WVMI Confidential and Proprietary

45. Surgical Care Scoring • Sip13 will no longer be scored beginning with discharges >=1/1/2013 • Sip13 will remain on the 2Q exit report and will be scored for discharges <1/1/2013 • 2Q scoring algorithms include discharges >=1/1/2013 WVMI Confidential and Proprietary

46. Frail Elderly • The inpatient Frail Elderly questions will not be reviewed at this time • Catnum 54 cases (CGPI) will get the dementia questions in the Frail Elderly instrument • If the answer to q1 (demendx) is “no” you will go to the end of the module • Otherwise the module will end after q9 (demlab) WVMI Confidential and Proprietary

47. FE Scoring • FE 13, 14, 15, 16, 17 and 19b have been discontinued and will no longer appear on the exit report WVMI Confidential and Proprietary

48. No changes…… • There are no changes to Delirium Risk, Fall Assessment or Inpatient Medication Reconciliation modules WVMI Confidential and Proprietary

49. Pilot Exit Report Changes • The Pilot Exit report has been revised and renamed and is now called the Combined Cohorts Exit Report • The report will provide scores for VHA designated non-core ORYX measures and pilot indicators • Mrec42 has changed from pilot to non-core • The other Med Recon and Frail Elderly (including FE8-Risk for Delirium) measures as well as cod1b are still on the report under the Pilot heading • The GM measures are now on a separate exit report (more on that later) WVMI Confidential and Proprietary

50. Global Measures WVMI Confidential and Proprietary