problem list and comorbidity notices webex justine carr john unterborn karen hughes january 2013 1
TRANSCRIPT
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Problem List and Comorbidity Notices Webex
Justine Carr
John Unterborn
Karen Hughes
January 2013
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Problem List as Efficient New Source of Patient Information• The problem list is now a required part of the medical
record.– Efficient abstract at discharge– Shared among caregivers for continuity
• Physicians/LIPs must update and maintain this list.– Enter problems as they appear– Edit status at discharge– If you are going (or have gone) off service, you should still add
the problem, if it is accurate
• Problems should appear in 3 places– On the list AND in the daily note AND in the d/c summary
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Why is the Problem List important?
Problem
List
Alerts all hospital care
givers of new
problems to modify
care plan
Alerts care givers
post discharge of
problems
Alerts care givers
on subsequent
admission
Ensures capture of
patient complexity for
coders (affects risk
adjustment and payment)
Achieves requirement
for Hospital’s
Meaningful EHR Use
Certification
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When to Add Problems to Problem List?
Admission
Automated
Trigger
Notice
New clinical
issue
Transfer
serviceDischarge
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What Problems Should Be Added?
• Diagnoses– Reason for admission
• E.g. diabetic ketoacidosis
– Chronic problems• E.g. atrial fibrillation; hypertension; COPD
• Comorbid Conditions– Present on admission
• E.g. urinary tract infection; hypernatremia
– Acquired during hospital stay• E.g. acute renal failure
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Who adds problems to the problem list?• Last year, Nurses added problems to the
problem list.• This year, Licensed Independent Practitioners
(MD, DO, NP, PA, Midwife) need to add problems to the problem list and manage the problem list to insure completeness as part of the discharge information for the next care giver.
• Next year, we are asking Meditech to improve information flow between problem list and nurse care plan
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Automated Problem List assistance
• Lab-driven alerts for selected diagnoses Comorbidity Noticeo This is a developing piloto Initial prompts: renal failure, respiratory failure, DKAo New prompts (1/31/13): acidosis, alkalosis,
hypernatremia, hyponatremia, pancytopenia
• Electronic “Page one” at discharge to review and update the problem list
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Ensuring Documentation Completeness
Clin
Doc
Special
ist
•Review
charts
periodicallyComorib
idity
Alerts
•Real time
surveillanceCode
rs
•Final check
at
discharge
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Automated assistance for Problem ListLab test exceeds
threshold
• Alert sent to
Ordering and
Attending MD
• My Notices
• Comorbidity
Report
MD views Alert
notice
• Problem
added if
accurate
statement.
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Comorbidity Alerts: Dec 10, 2012ICD 9 Code
ICD 9 Code Description Clinical Triggers Meditech Message -
250.13DKA DIABETES WITH KETOACIDOSIS TYPE I, UNCONTROLLED
Glucose > 300 mg/dl AND Anion Gap > 12
This patient has hyperglycemia (glucose > 300 )and widened anion gap consistent with DKA
250.12DKA DIABETES WITH KETOACIDOSIS TYPE II, UNCONTROLLED
Glucose > 300 mg/dl AND Anion Gap > 12
This patient has hyperglycemia (glucose > 300 )and widened anion gap consistent with DKA
584.9ACUTE RENAL FAILURE
Creatinine > 1.5 mg/dl AND Creatinine increase of > 0.5
mg/dl
This patient has a Creatinine > 1.5 and an increase > 0.5 since the last test
518.84ACUTE AND CHRONIC RESPIRATORY FAILURE
pH < 7.35 and pC02 > 50 OR pO2 < 60
This patient has hypoxemia or a respiratory acidosis with pCO2 > 50 mm/Hg
518.83ACUTE RESPIRATORY FAILURE
pH < 7.35 and pC02 > 50 OR pO2 < 60
This patient has hypoxemia or a respiratory acidosis with pCO2 > 50 mm/Hg
518.81CHRONIC RESPIRATORY FAILURE
pH < 7.35 and pC02 > 50 OR pO2 < 60
This patient has hypoxemia or a respiratory acidosis with pCO2 > 50 mm/Hg
Meditech Message – This alert has been automatically generated from pre-set laboratory thresholds but requires clinical correlation
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Comorbidity Alerts: Jan 31, 2013ICD 9 Code
ICD 9 Code Description Clinical Triggers Meditech Message
276.2 ACIDOSIS pH < = 7.35 This patient has pH<=7.35
276.3 ALKALOSIS pH> 7.47 This patient has pH> 7.47
276.0HYPEROSMOLALITY and/or hypernatremia
Sodium >150This patient has hyperosmolality or a Serum Sodium result > 150.
276.1HYPOSMOLALITY and/or hyponatremia
Sodium <130This patient has hyposmolality or a Serum Sodium result < 130.
284.19 PANCYTOPENIAHct < 30% and WBC
<4K and Platelets <100K
This patient has anemia, leukopenia and thrombocytopenia.
Meditech Message – This alert has been automatically generated from pre-set laboratory thresholds but requires clinical correlation
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Comorbidity Notices for Multiple Patients > Click on notice to review
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pH <7.35 triggers Acidosis
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Acidosis w/comment detail > Save
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Acidosis now appears on Problem List
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Reconciliation of Problems at Discharge• Problems pull into the Electronic Page 1
– Edit/update the problem list at discharge
• Benefits– Up to date current list is shared with patient and next
provider of care as required by Meaningful Use– Problem list is current if the patient is re-admitted at a
later time
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Click Document to Begin the E-Page 1
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Click New in the footer
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Click Discharge Referral
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Referral Opens, Problems pull into E-Page 1
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Problems from summary panel pull in and the display will
say “Entered”
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Click Problem field to view/edit/update
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To Update the List, Click Edit in Footer
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If a problem is no
longer active,
click on EDIT.
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Click on Status to change ARF to Resolved > Save
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This notice was automatically generated from a pre-set lab threshold and requires clinical correlation.
This patient has a creatinine greater than 1.5 or an increase of greater than 0.5 mg/dl since last test
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Problem List Updated E-page 1
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Click OK to return to the E-page
1 and enter additional
information
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View of completed page 1
prior to entering your PIN to
Sign/Save
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Questions or Suggestions
• Contact:– VPMA at your hospital– Justine Carr, MD [email protected]
– Karen Hughes [email protected]