6/11/2014 12:59:15 PM
Attestation for Meaningful Use 2 in Virtua’s hospitals will begin on July 1. There are many new requirements for Meaningful Use 2 (MU2). Some of these requirements necessitate additional data input by providers and nurses. The IS team tried to minimize the impact of meaningful use to on the clinicians, but there are some measures for which impact is unavoidable. This will explain some of the measures that will impact providers. These changes will be in effect as of June 10, 2014.
Problem List
One of the MU2 measures requires that the patient receive an electronic summary of his/her hospitalization. This summary must have certain specified data elements. Many of these elements already exist in the medical record, so will be pulled to the summary electronically. However, there are some measures which we do not currently capture routinely. The Problem List is one of those required data items.
Currently in Soarian, there is a section where the patient’s Problem List can be entered and managed. Please refer to the screenshot below. The Problem List is located under the “charting” tab, in the section called “CDP”. At the bottom section of the screen is where the problem list can be entered.
Clicking on the plus sign in the Problems section will bring up a window which allows you to search for problems and then enter them. This process is somewhat arduous, but can be used and will result in the list of problems populating the patient summary of care.
However, in order to try to make the problem list generation fit into the provider’s workflow more easily, we have built a new order which contains a list of common problems. There are actually 3 orders, one for Med/Surg, one for Pediatrics, and one for Mother Baby. These orders will be incorporated into all of the admission order sets. See the screenshot below for the appearance of the Med/Surg order. When this order appears, simply clicking the checkbox next to the problem will result in that particular problem populating the CDP once the order is signed.
This will make the process of adding problems to the problem list quite easy for these common problems. Problems that are not listed in the order will need to be added directly into the CDP. At the time of discharge, problems that are no longer relevant can be inactivated as indicated in the screenshot below.
Please use the problem list orders and the CDP to provide the patient with an accurate and timely problem list upon discharge.
Family History
A 2nd MU2 requirement for which we will use an order to facilitate the data entry is Family History. The requirement is that patients have one first-degree relative with at least one element of family history captured discreetly. We know that family history is routinely captured in the dictated History and Physical, but this is simply free text and therefore does not meet the MU2 requirement.
So, we built an order for Family History. Please refer to the screenshot below. All is required is that you choose one family member, and choose one Family History item from the drop-down. It is okay to choose “Not Known”.
Cognitive Status
Another requirement of MU2 is that there is an indication of the patient’s cognitive status at the time of discharge. To meet this measure, a required field has been added to the Adult, L&D, and Post-partum Discharge Instructions template:
The choices are ‘Awake and Alert’ and ‘Other’. If you choose ‘Other’, you must type a comment.
We are sorry for the inconvenience that this causes, but these are requirements that we must meet. We will continue to search for solutions that make this process more convenient, while continuing to meet the measures.