Record Demographics and Advance Directives

Configuring RPMS-EHR for Meaningful Use

Resource Patient Management System

Presenters:

Jason Loepp, RHIAHIM Director, Cherokee Nation Health Services

Lisa Lyon, BSN, RN, CDEClinical Informatics Coordinator, Cherokee Nation Health Services

Toni Potts, BBAClinical Applications Coordinator Manager,

Cherokee Nation Health Services

Record Demographics and Advance Directives

Training Objectives• Understand the MU objectives and the measures• Record the required elements (Preferred Language,

Race, Ethnicity, Date & Preliminary Cause of Death)• Document Advance Directives in both Patient

Registration & appropriate TIU Note Titles• Generate TIU/SSD list of titles to verify Advance

Directive is associated with the correct title • Verify scanned Advance Directive documents are

associated with the correct note title

Record Demographics and Advance Directives

Record Demographics Objective and Measure

Record all of the following demographics:• Gender, date of birth• Preferred language, race, ethnicity• *Date and preliminary cause of death in the event of

mortality in the eligible hospital or CAH More than 50% of all unique patients seen by the provider or admitted to the hospital’s inpatient or emergency department have demographics recorded as structured data.

Record Demographics

MU Measure

Type of Measure: Rate

The number of unique patients in the denominator who have all the elements of demographics (or a

specific exclusion if the patient declined to provide one or more elements or if recording an element is contrary to state law) recorded as structured data. >50%The number of unique patients seen by the

provider during the EHR reporting period.

Record Demographics

RPMS Reporting Logic

Denominator Inclusions:COUNT: each patient

HAVING: one or more face-to-face visits with the provider during the EHR reporting period

Record Demographics

RPMS Reporting Logic

Numerator Inclusions:COUNT: each patient in the Denominator

WHERE: structured data is present during the EHR reporting period for each of the following data elements:

Preferred language GenderRace EthnicityDate of birth

OR WHERE: a structured data element is present indicating:THAT: The patient declines to provide the data element

informationOR THAT: Capturing the race and ethnicity is against state law

Record Demographics

RPMS Reporting Logic

Measure Exclusion: None

Record Demographics

Advance Directives Objective and Measure

Record advance directives for patients 65 years old or older.More than 50% of all unique patients 65 years old or older admitted to the hospital’s inpatient department have an indication of an advance directive status recorded as structured data.

Advance Directives

MU Measure

Type of Measure: Rate

The number of unique patients in the denominator with an indication of an advanced directive entered

using structured data. >50%The number of unique patients age 65 or older admitted to an eligible hospital's or CAH's inpatient

department (POS 21) during the EHR reporting period.

Advance Directives

RPMS Reporting Logic

Denominator Inclusions:COUNT: each patient

HAVING: an age of 65 years or older on date of admissionAND HAVING: one or more admission dates to a

hospital's or CAH's inpatient department (POS 21) during the EHR reporting period, defined as Service Category of H

Advance Directives

RPMS Reporting Logic

Numerator Inclusions:COUNT: each patient in the Denominator

WHERE: structured data is present indicating one or more of the following conditions:– A note title in the TIU Document Class

"Advance Directive.“– An Advance Directive value of "Yes" or

"No"

Advance Directives

RPMS Reporting Logic

Measure Exclusion: • Eligible hospitals and CAHs who have no

patient admissions for patients with an age of less than 65 years on date of admission during the EHR reporting period are excluded from this measure.

Advance Directives

What HIM Needs to Know

Record Demographics and Advance Directives

• Patient Registration Parameters for Race, Ethnicity & Preferred Language should be set to mandatory

• The Underlying Cause of Death is recorded in ADT or PCC using the UCD mnemonic

• Patient Registration records presence or absence of Advance Directive

• Presence of an Advance Directive is recorded using a TIU note title “Advance Directive”

• HIM should routinely perform a search using the SSD menu for quality control

Configuration• Patient Registration parameters should be set

to mandatory• Advance Directive note title must be under

Advance Directive document class

Record Demographics and Advance Directives

How-to Session• Set to mandatory the Patient Registration Parameters for

Race, Ethnicity & Preferred Language• Record Race, Ethnicity and Preferred Language in Patient

Registration • Record the Underlying Cause of Death in ADT or PCC using the

UCD mnemonic• Record presence or absence of Advance Directive in Patient

Registration• Record presence of an Advance Directive using TIU note title• Search Advance Directive note titles using SSD menu for the

purpose of quality control

Record Demographics and Advance Directives

Policy and Procedure

Review

Record Demographics and Advance Directives

How-to Session

Questions & Discussion

Record Demographics and Advance Directives