Using Smart Forms to Discretely Capture Stroke Data for ...c .Using Smart Forms to Discretely Capture

Using Smart Forms to Discretely Capture Stroke Data for ...c .Using Smart Forms to Discretely Capture

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  • Using Smart Forms to Discretely Capture Stroke Data for Electronic Reporting

    Elaine Tsiakopoulos, RN, MSN, Shondralis Allen, BS, Janet Gervasio, MSN, RN-BC,PMP James R. Brorson, MD, Cedric McKoy, APN, Pedro Vivar Cruz, MD, Susan Richter, RN, MS

    Background Aims

    The Intervention

    Lessons Learned

    To accurately capture discrete data for reporting on Stroke Quality Measures for the CMS IQR program To maximize compliance with the MU-EH EHR incentive payment program To decrease manual abstraction times

    Collaboration between the Epic team, Quality team, CBIS team, and Neurology team to coordinate capturing discrete data components necessary for reporting Methods had to fit Neurology providers workflow & capture data discretely according to MU specifications.

    The Smart Form and NIHSS can be pulled into any Notewriter on the fly by a provider with the use of a Smart Phrase:

    .NEUROSTROKE (Figure 1). .NIHSTROKESCALE (Figure 4).

    Designed as intuitive one click documentation (Figures 1& 2), auto-generating text for note (Figure 3) while capturing discrete data for 2 areas of required reporting use: MU-EH CQMs and CMS IQR Core Measures. Auto Cascading of Reasons Not Given for intervention, allowing for at a glance view of all Quality Measures required for documentation (Figure 2). Auto Calculation of NIHSS total score (Figure 4). Hover to discover functionality detailed the definition and the descriptions for documentation for both the Rankin Scale and NIHSS score (Figure 4).

    Education was provided on October 29th, 2013 to all Neurology Residents with a TipSheet Use was measured through abstraction of Core Measures and validation of MU CQMs

    Provider participation and buy-in was essential to the success and usefulness of the Smart Form Adding additional meaningful components requested by the providers to the Smart Form maximized participation

    Next Steps

    Results

    After the implementation of the Smart Form in October 2013, measure performance was at 100% for 3 consecutive months. Prior to the implementation of the Smart Form, there were 1 3 outliers per month with low performance in March & April 2013 below the mean.

    Beginning with January 2013 discharges, the Center for Medicare & Medicaid Services (CMS) Inpatient Quality Reporting (IQR) Program required reporting on the new Stroke Quality Measures:

    STK2 Antithrombotic at discharge STK3 Anticoagulant at discharge STK4 Thrombolytic therapy STK5 Antithrombotic by hospital day 2 STK 6 Statin at discharge STK10 Assessed for rehabilitation

    The measures were also a part of the CMS Electronic Heath Record (EHR) Incentive Program called Meaningful Use (MU) Eligible Hospitals (EH) Clinical Quality Measures (CQMs) which required discrete data. Data was manually abstracted and required discrete elements to participate in the EHR Incentive Program.

    Continue to audit & validate data capture and measure performance for meaningful change

    Contact: Elaine.Tsiakopoulos@uchospitals.edu

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    G4P Std. Campaign Baseline

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    G4P Std. Campaign Baseline

    Baseline: 58.0% Standard HH Campaign: 72.3%, p