1. Strategic – Proactive Review and Setup VTE/Stroke Meaningful Use Clinical Rules 2014 Guidelines

2.  Review of UMLS (2014 requirements) ◦ And formerly HITSP  Clinical Quality Measures review  Value Set review  Evaluate site specific criteria to implement 5 clinical decision support “interventions” ◦ MU Stage II requirement  End with clear understanding and mini-toolset to initiate/finalize site specific conversations regarding these MU Stage II requirements Note: the Client Server 5.66 platform was utilized for the basis of this presentation

3.  WILL NOT review global Meaningful Use items  WILL NOT interpret ARRA/CMS code  WILL NOT provide actual Plug-N-Play rules for production ◦ Due to the nature and complexity of these rules, future Webinars will cover actual build and rollout Advanced Rules - VTE-Stroke Deployment

4.  Healthcare Information Technology Standards Panel (HITSP)  Unified Medical Language System (UMLS) ◦ RxNorm ◦ LOINC ◦ SNOMED ◦ ICD-9 ◦ ICD-10 “..The value sets contain all the data elements previously found in HITSP TN906 v1.1 specifications. Upon reviewing the value sets, it will be clear that the reliance on codified data has increased exponentially. National and international standards are becoming a necessity for exchanging data for interoperability and for quality reporting. “

5. MEDITECH's Best Practice documents contain workflow methods which have been vetted through numerous clinical and customer representatives. The corresponding SQL reports have been created with precise alignment to the workflow methods found within the Best Practice documents in conformance with the 2014 specifications. 1

6.  “Use clinical decision support to improve performance on high-priority health conditions” [For Stage II]…Implement 5 clinical decision support interventions related to 4 or more clinical quality measures, if applicable, at a relevant point in patient care for the entire EHR reporting period.

7. CMS eMeasure IDNQF #Measure TitleMeasure Description 1040435 Stroke-2 Ischemic stroke – Discharged on anti-thrombotic therapy. Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge. 710436 Stroke-3 Ischemic stroke – Anticoagulation Therapy for Atrial Fibrillation/Flutter Ischemic stroke patients with atrial fibrillation/flutter who are prescribed anticoagulation therapy at hospital discharge. 910437 Stroke-4 Ischemic stroke – Thrombolytic Therapy Acute ischemic stroke patients who arrive at this hospital within 2 hours (120 minutes) of time last known well and for whom IV t-PA was initiated at this hospital within 3 hours (180 minutes) of time last known well. 720438 Stroke-5 Ischemic stroke – Antithrombotic therapy by end of hospital day two Ischemic stroke patients administered antithrombotic therapy by the end of hospital day two. 1050439 Stroke-6 Ischemic stroke – Discharged on Statin Medication Ischemic stroke patients with LDL greater than or equal to 100 mg/dL, or LDL not measured, or, who were on a lipid- lowering medication prior to hospital arrival are prescribed statin medication at hospital discharge.

8. CMS eMeasure IDNQF #Measure TitleMeasure Description 1070440 Stroke-8 Ischemic or hemorrhagic stroke – Stroke education Ischemic or hemorrhagic stroke patients or their caregivers who were given educational materials during the hospital stay addressing all of the following: activation of emergency medical system, need for follow-up after discharge, medications prescribed at discharge, risk factors for stroke, and warning signs and symptoms of stroke. 1020441 Stroke-10 Ischemic or hemorrhagic stroke – Assessed for Rehabilitation Ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services.

9.  Stroke-2 (ischemic) ◦ Discharged on Antithrombotic Therapy  Stroke-3 (ischemic) ◦ Discharged on Anticoagulation Therapy ◦ Atrial Fibrillation/Flutter  Stroke-4 (ischemic) ◦ Thrombotic Therapy – 2 hr arrival/3 hr IV t-PA  Stroke-5 (ischemic) ◦ Antithrombotic therapy by end of hospital day 2  Stroke-6 (ischemic) ◦ Discharged on Statin Medication (LDL>100 or prior use)  Stroke-8 (ischemic/hemorrhagic) ◦ Stroke Education  Stroke-10 (ischemic/hemorrhagic) ◦ Assessed for Rehabilitation

10. You are not required to use all items in a value set in your system. You can choose to use only those which most closely match your workflow and patient needs. However, any items you do include must be mapped to the standard nomenclature. For example, when creating a group response for contraindications for ordering a medication, all of the reasons in the value set do not have to be included. The elements in the group response must all come from the value set and must all be mapped to the nomenclature specified in the value set. 1 1 Data Capture for Stroke/VTE Measures, MEDITECH CS Best Practice Documentation

11.  Medication, Discharge: Anticoagulant Therapy using Anticoagulant Therapy RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.200)  Medication, Order: Thrombolytic (t-PA) Therapy using Thrombolytic (t-PA) Therapy RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.226)  Medication, Administered: Antithrombotic Therapy using Antithrombotic Therapy RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.201).  Medication, Discharge: Statin using Statin RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.225).

12.  The following value sets are used for stroke diagnosis: ◦ Diagnosis, Active: Hemorrhagic Stroke using Hemorrhagic Stroke Grouping value set (2.16.840.1.113883.3.117.1.7.1.212). ◦ Diagnosis, Active: Ischemic Stroke using Ischemic Stroke Grouping value set (2.16.840.1.113883.3.117.1.7.1.247).

13.  Value set for the LDL test: ◦ Laboratory Test, Result: LDL-c using LDL-c LOINC Value Set (2.16.840.1.113883.3.117.1.7.1.215).  Value sets for Palliative Care: ◦ Intervention, Order: Palliative Care using Palliative Care SNOMED CT Value Set:(2.16.840.1.113883.3.526.2.1076). ◦ Intervention, Performed: Palliative Care using Palliative Care SNOMED CT Value Set: (2.16.840.1.113883.3.526.2.1076).

14. CMS eMeasure IDNQF #Measure TitleMeasure Description 1080371 Venous Thromboembolism (VTE)-1 VTE prophylaxis This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission. 1900372 VTE-2 Intensive Care Unit (ICU) VTE prophylaxis This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after the initial admission (or transfer) to the ICU or surgery end date for surgeries that start the day of or the day after ICU admission (or transfer).

15. CMS eMeasure IDNQF #Measure TitleMeasure Description 730373 VTE-3 VTE Patients with Anticoagulation Overlap Therapy This measure assesses the number of patients diagnosed with confirmed VTE who received an overlap of parenteral (intravenous [IV] or subcutaneous [subcu]) anticoagulation and warfarin therapy. For patients who received less than five days of overlap therapy, they must be discharged on both medications or have a reason for discontinuation of overlap therapy. Overlap therapy must be administered for at least five days with an international normalized ratio (INR) greater than or equal to 2 prior to discontinuation of the parenteral anticoagulation therapy, discharged on both medications or have a reason for discontinuation of overlap therapy. 1090374 VTE-4 VTE Patients Receiving Unfractionated Heparin (UFH) with Dosages/Platelet Count Monitoring by Protocol (or Nomogram) This measure assesses the number of patients diagnosed with confirmed VTE who received intravenous (IV) UFH therapy dosages AND had their platelet counts monitored using defined parameters such as a nomogram or protocol.

16. CMS eMeasure IDNQF #Measure TitleMeasure Description 1100375VTE-5 VTE discharge instructions This measure assesses the number of patients diagnosed with confirmed VTE that are discharged to home, home care, court/law enforcement or home on hospice care on warfarin with written discharge instructions that address all four criteria: compliance issues, dietary advice, follow-up monitoring, and information about the potential for adverse drug reactions/interactions. 1140376 VTE-6 Incidence of potentially preventable VTE This measure assesses the number of patients diagnosed with confirmed VTE during hospitalization (not present at admission) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date.

17.  VTE-1 ◦ VTE Prophylaxis  VTE-2 ◦ ICU VTE Prophylaxis  VTE-3 (confirmed VTE) ◦ Anticoagulation Overlap Therapy (IV/SQ and Warfarin) for 5 days (INR>2)  VTE-4 (confirmed VTE) ◦ Unfractionated Heparin AND monitored platelets  VTE-5 (confirmed VTE) ◦ Discharge Instructions  VTE-6 (confirmed VTE during stay) ◦ Not present at admission and did not receive VTE prophylaxis

18.  Value sets for Pharmacologic Prophylaxis: ◦ Medication, Administered: Direct Thrombin Inhibitor using Direct Thrombin Inhibitor RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.205). ◦ Medication, Administered: Injectable Factor Xa Inhibitor using Injectable Factor Xa Inhibitor RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.211). ◦ Medication, Administered: Low Molecular Weight Heparin using Low Molecular Weight Heparin RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.219). ◦ Medication, Administered: Oral Factor Xa Inhibitor using Oral Factor Xa Inhibitor RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.134). ◦ Medication, Administered: Unfractionated Heparin using Unfractionated Heparin RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.218). ◦ Medication, Order: Parenteral Anticoagulant using Parenteral Anticoagulant RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.266). ◦ Medication, Administered: Warfarin using Warfarin RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.232).  If unfractionated heparin is used, the following value sets regarding Route of Administration will be checked: ◦ Attribute: Route: Subcutaneous route using Subcutaneous route SNOMED-CT Value Set (2.16.840.1.113883.3.117.1.7.1.223). ◦ Attribute: Route: Intravenous route using Intravenous route SNOMED-CT Value Set (2.16.840.1.113883.3.117.1.7.1.222).

19.  Value Set for INR Procedure: ◦ Laboratory Test, Result: INR using INR LOINC Value Set (2.16.840.1.113883.3.117.1.7.1.213).  Value sets for Palliative Care: ◦ Intervention, Order: Palliative Care using Palliative Care SNOMED CT Value Set:(2.16.840.1.113883.3.526.2.1076). ◦ Intervention, Performed: Palliative Care using Palliative Care SNOMED CT Value Set: (2.16.840.1.113883.3.526.2.1076).

20.  The VTE measures use the following value set from VSAC to determine VTE population: ◦ Diagnosis, Active: Venous Thromboembolism using Venous Thromboembolism Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.279). ◦ Diagnosis, Active: Atrial Fibrillation/Flutter using Atrial Fibrillation/Flutter Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.202).  The following value sets are used to exclude patients: ◦ Diagnosis, Active: Obstetrics VTE using Obstetrics VTE Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.264). ◦ Diagnosis, Active: Obstetrics using Obstetrics Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.263). ◦ Diagnosis, Active: Hemorrhagic Stroke using Hemorrhagic Stroke Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.212). ◦ Diagnosis, Active: Ischemic Stroke using Ischemic Stroke Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.247). ◦ Diagnosis, Active: Mental Disorders using Mental Disorders Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.262).

21.  Value set for Diagnostic Test: ◦ Diagnostic Study, Result: VTE Diagnostic Test using VTE Diagnostic Test Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.276).  Value Set for confirmed VTE: ◦ Attribute: Result: VTE Confirmed using VTE Confirmed SNOMED CT Value Set (2.16.840.1.113883.3.117.1.7.1.407).

22.  Patient age  Resuscitation status  Problem List  Provider – yes/no  Diagnosis vs. Problem List  Drug Type (AHFS Classification) ◦ Inpatient “active” medication orders ◦ Ambulatory “active” medication orders  “Confirmed VTE” ◦ Procedure Status vs. SNOMED CT Value Set content  Monitored LAB values

23. Challenges

24.  Site Specific Workflow ◦ Patient Assessments (VTE/Stroke)  Performed when and by whom ◦ Dictionary Specific Build  Standardization for multi-site facilities ◦ Provider/Physician Expectations  Required at Order Entry?  Admission criteria ◦ Inclusion/Exclusion (e.g. ICU direct admit)

25.  Medication Identification – PHA Drug Formulary Drug Type Customer Defined Parameter

26.  Medication Identification – PHA Drug Formulary ◦ Value Set differences (HITSP/VSAC)  Stroke has Warfarin, VTE DOES NOT!

27.  Medication Identification – RXM Drug Drug Type

28.  “Provider” Identification ◦ MIS User Dictionary  Profile  This User is Provider

29.  “Diagnosis” Identification ◦ Typically done post discharge in ABS by Coders ◦ Problem List ◦ New Keywords for rules (Magic and CS)  [f pt prob current]

30.  “Confirmed” VTE ◦ What determines a “complete”/”reported” exam and/or procedure  At what point does the Status change ◦ Role based, multi-collaborative process

31.  Where Rules are attached Remember  …relevant point in patient care… ◦ POM Enabled ◦ OE/OM Categories  MED  LAB  MIC  RAD ◦ PHA/POM Enabled Rules  “Global” in PHA Customer Defined Parameters ◦ Less Popular - Underutilized  PHA Refill Rules  LAB Verify Rules

32. Examples

33.  Description ◦ Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge.  Initial Patient Population ◦ Patients admitted to the hospital for inpatient acute care with a principal diagnosis code for ischemic or hemorrhagic stroke with hospital stays <= 120 days during the measurement period for patients age 18 and older at the time of hospital admission.

34.  NQF 0435 Measure captures patients who are prescribed antithrombotic therapy at discharge. ◦ In the 2011 specifications, HITSP provided a SNOMED code to use to document the provider’s intention to send the patient home on a specific discharge medication. This SNOMED was INT and was used in a query on an order in POM. This allowed an alternate workflow to documenting discharge medications in discharge. However, this SNOMED code is not included in the 2014 specifications. Therefore, no alternate workflow is possible. All discharge medications must be documented through the Discharge routine.

35.  Rule Logic must contain ◦ Ischemic Stroke “diagnosis” ◦ NOT Comfort Care (resuscitation order) ◦ Patient age > 18 ◦ Length of Stay < 120 days ◦ Antithrombotic therapy at discharge  Home Meds/Discharged Meds

38.  Description ◦ This measure assesses the number of patients diagnosed with confirmed VTE who received overlaps of parenteral (intravenous [IV] or subcutaneous [subcu]) anticoagulation and warfarin therapies. Patients who received fewer than five days of overlap therapy should be discharged on both medications or have a reason for discontinuation of overlap therapy. Overlap therapy should be administered for at least five days with an international normalized ratio (INR) greater than or equal to two prior to discontinuation of the parenteral anticoagulation therapy, discharged on both medications, or have a reason for discontinuation of overlap therapy.  Initial Patient Population ◦ Patients with a diagnosis code for venous thromboembolism (VTE), a patient age greater than or equal to 18 years, and a length of stay less than or equal to 120 days.

39.  NQF 0373 Measure captures patients who are prescribed antithrombotic therapy at discharge. ◦ In the 2011 specifications, HITSP provided a SNOMED code to use to document the provider’s intention to send the patient home on a specified discharge medication. This SNOMED was INT 40 and was used in a query on an order in POM. This allowed an alternate workflow to documenting discharge medications in discharge. However, this SNOMED code is not included in the 2014 specifications. Therefore, no alternate workflow is possible. All discharge medications must be documented through the Discharge routine.

40.  Rule Logic must contain ◦ Confirmed VTE ◦ NOT Comfort Care (resuscitation order) ◦ Patient age > 18 ◦ Length of Stay < 120 days ◦ 5+ days with INR > 2 ◦ Inpatient IV Anticoagulant Therapy ◦ Inpatient PO Anticoagulant Therapy ◦ Ambulatory PO Anticoagulant Therapy

44. Stroke 2 VTE 3

45.  Potential MEDITECH Functionality Additions ◦ Rule Evaluation  At “Open Chart” via EMR ◦ Discharge Functionality  Multi-collaborative  DON’T GET US STARTED!  Stage 3 Recommendations ◦ “…Implement 15 clinical decision support interventions or guidance related to five or more clinical quality measures that are presented at a relevant point in patient care for the entire EHR reporting period…” 2 2 SGRP113: Clinical Decision Support, Draft Recommendations Meaningful Use Stage 3, Paul Tang et al

46. Kevin McConnell, PharmD, PHD. Co-founder and Executive VP of Service Delivery Kevin has 24 years of relevant professional experience including over 13 years’ experience as a MEDITECH consultant, project manager, and application specialist in healthcare system implementation and assessments. Specializing in the implementation and support of MEDITECH’s Advanced Clinical Applications and related applications and interfaces. Areas of expertise include Meaningful Use assessments and planning, pre and post implementation assessments, developing implementation and training plans, revenue cycle, coordinating process and departmental workflow enhancement/redesign, facilitating/managing application implementation teams, training end-users and change management. Past positions include, but are not limited too, Director of Pharmacy, Clinical Pharmacist, Staff Pharmacist, Instructor at a College of Pharmacy, and owner of a retail/community pharmacy. Kevin is a frequent Presenter at the Annual MUSE International Conferences including topics such as Writing Clinical Rule and PHA/NPR for Dummies.