1. Problem List and Comorbidity Notices Webex Justine Carr John Unterborn Karen Hughes January 2013 1

2. 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 2

3. 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 3

4. When to Add Problems to Problem List? Admission Automated Trigger Notice New clinical issue Transfer service Discharge 4

5. 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 5

6. 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 6

7. Automated Problem List assistance Lab-driven alerts for selected diagnoses Comorbidity Notice o This is a developing pilot o Initial prompts: renal failure, respiratory failure, DKA o New prompts (1/31/13): acidosis, alkalosis, hypernatremia, hyponatremia, pancytopenia Electronic “Page one” at discharge to review and update the problem list 7

8. Ensuring Documentation Completeness Clin Doc Specialist Review charts periodically Comoribidity Alerts Real time surveillance Coders Final check at discharge 8

9. Automated assistance for Problem List Lab test exceeds threshold Alert sent to Ordering and Attending MD My Notices Comorbidity Report MD views Alert notice Problem added if accurate statement. Discharge review of problem list Problem designated as active, resolved, ruled out, inactive. 9

10. Comorbidity Alerts: Dec 10, 2012 ICD 9 Code ICD 9 Code DescriptionClinical Triggers Meditech Message - 250.13 DKA 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 250.12 DKA 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 584.9 ACUTE 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 518.84 ACUTE AND CHRONIC RESPIRATORY FAILURE pH 50 OR pO 2 < 60 This patient has hypoxemia or a respiratory acidosis with pCO2 > 50 mm/Hg 518.83 ACUTE RESPIRATORY FAILURE pH 50 OR pO 2 < 60 This patient has hypoxemia or a respiratory acidosis with pCO2 > 50 mm/Hg 518.81 CHRONIC RESPIRATORY FAILURE pH 50 OR pO 2 < 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 10

11. Comorbidity Alerts: Jan 31, 2013 ICD 9 Code ICD 9 Code DescriptionClinical Triggers Meditech Message 276.2ACIDOSISpH < = 7.35This patient has pH<=7.35 276.3ALKALOSISpH> 7.47This patient has pH> 7.47 276.0 HYPEROSMOLALITY and/or hypernatremia Sodium >150 This patient has hyperosmolality or a Serum Sodium result > 150. 276.1 HYPOSMOLALITY and/or hyponatremia Sodium <130 This patient has hyposmolality or a Serum Sodium result < 130. 284.19PANCYTOPENIA Hct < 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 11

12. Comorbidity Notices for Multiple Patients > Click on notice to review 12

13. pH <7.35 triggers Acidosis 13

14. Acidosis w/comment detail > Save 14

15. Acidosis now appears on Problem List 15

16. 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 16

17. Click Document to Begin the E-Page 1 17

18. Click New in the footer 18

19. Click Discharge Referral 19

20. Referral Opens, Problems pull into E-Page 1 20 Problems from summary panel pull in and the display will say “Entered”

21. Click Problem field to view/edit/update 21

22. To Update the List, Click Edit in Footer 22 If a problem is no longer active, click on EDIT.

23. Click on Status to change ARF to Resolved > Save 23 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

24. Problem List Updated E-page 1 24 Click OK to return to the E-page 1 and enter additional information

25. 25 View of completed page 1 prior to entering your PIN to Sign/Save

26. Questions or Suggestions Contact: –VPMA at your hospital –Justine Carr, MD justine.carr@steward.org –Karen Hughes karen.hughes@steward.org 26