The Top Ten Hospital OQR Mismatches from Q2 2012 – Q1 2013 and
Ways to Improve Your ED-Throughput:
Questions and Answers
April 16, 201410:00 a.m. ET Moderator:
Mollie Carpenter, RN, BSN
Educational Coordinator, Hospital OQR Program SC
Speaker:
Laurie Ciannamea, MBA, CHCO Project Coordinator, FMQAI
Question 1: Yes, I had a question on slides 20 and 21. I wasn't clear. In one place it
said that there had to be an exam by the provider, and then in another place it said that a T-sheet with a time of contact was acceptable. So, could you go through that piece again? Like the first bullet point says if the exam is documented…
Answer 1: Right. If the T-sheet is being used, there is documentation of the exam on
the T-sheet. If you look at the example on page 21, you'll see that there is a space for documentation of the physical exam. And so, in order for the T-sheet to be an acceptable source, you would use that documentation of a physical exam to substantiate that there was direct, personal contact between the provider and the patient.
Question 2: Hello. My question is regarding the provider contact time. On our
electronic health record we have an ED patient care timeline, and it has a time and then the verbiage “patient seen by provider,” and then it has the MD's name, comma, MD. Is that adequate to abstract as the first time of contact?
Answer 2: Yes, that's very adequate. Let me just add to that for one second. If it is an ED log type of record, then there needs to be documentation of an exam in that record.
Question 3: Yes, hi. My question is in regards to the provider contact time as well.
Obviously, I think it's very confusing. I had submitted a question to
QualityNet about this. We have a status event history in our ED summary report that simply says “with MD,” and there's a time there. So I question whether or not we could use that, and I had gotten a response that there had to be documentation along with that, that supported that time, i.e., an exam, an evaluation, or an assessment.
But if I understand slide 19 correctly, if you simply have documentation of MD with patient – with MD – that that is okay to use. So could you clarify that, please?
Answer 3: What they're looking for is initially a face-to-face contact with the physician,
so initial provider contact. If you say, “MD at bedside” or “MD with patient,” that's acceptable, and then what they're looking for with that is something to substantiate that, such as an exam documented in that medical record. Does that make sense?
Question 4: Hi. I'm interested in the pain medication time for outpatient measures for
fracture pain. Can you please clarify when conscious sedation is used, and that anesthesia medications are not captured on the table that is identified with the measure?
Answer 4: If you look at the Specifications Manual, the specific, but not all-inclusive, list of analgesics is in the manual that is listed, and conscious sedation is not included as an anesthesia agent. Does that answer your question?
Question 4: No. Well, I guess – no, that doesn't answer my question because it says
that we are supposed to abstract anesthesia agents. So if the patient has, say, ketamine before they have another medication, you would include that as your earliest time as long as it is by the correct route, which it would be. And that ketamine is not listed as an analgesic because it's anesthesia. I wrote in a question to say, “Is there a table of anesthesia medications that are included,” and received “No, you just include any anesthesia agent.”
Answer 4: I'm going to – if you could, if you could write that in to me, again, to the
Hospital Outpatient, and let me look at that and maybe include the original incident number so I can look that over for you, I'd appreciate that.
Question 5: Hi. Thank you. My question is regarding slide 45. It states, “Beginning
with January 2014 encounters, if patient is admitted to observation, use the date of order for observation as date of departure.”
My question is that in our facility even if the patients are admitted for
observation, they do go from the emergency room to a floor for observation, so are we to use the time of the order or the time they physically depart the ER?
Answer 5: For 2014, January 1 encounters, they've changed observation. And what
they're looking for now for the abstraction is that you abstract the time of the observation order. And the reason for that is that, to bring the throughput for OP-18 into a logical sequence, they don't want people who have an order written for observation and end up sitting in the emergency room for
three hours waiting for a bed to obscure your throughput time. So they've changed that to say if the time of the order that's written for observation, that will be abstracted as the ED departure time. But there must be an order in the emergency department record for that observation order.
Question 6: Hi. I'm also an EMS Medical Director and am curious as to whether or not
EMS-administered pain management in long bone fractures meets the requirement if it's documented both on the EMS chart, of course, but then also by either nursing or by the physician that the patient received, for example, morphine in the field, and their pain is adequately controlled on arrival to the emergency department. Does that time count?
Answer 6: It does not, and the thought process there is that they want to exclude any
medications that are given prior to arrival so that that doesn't obscure the time frame that the patient would receive medication in the emergency room. So if the patient received morphine in the field by EMS and then they came in the ED and say that the doctor said, “Okay, in two hours I want to repeat that morphine dose,” then that's going to obscure the time frame of the initial medication given for pain management which would obscure the measure.
They've pretty much eliminated anything – any pain medication that's given prior to arrival within 24 hours, either given as a routine home medication, or as a documented PRN medication, or as medication given in the EMS system.
Question 8: All right. I have a couple of questions. The first one is just clarity. I know
I'm not allowed to use when the physician starts his history and physical; I'm not allowed to use the date and time he starts that, correct?
Answer 8: That's correct.
Question 8: Okay. Second, if I cannot find when he's seen the patient face-to-face but
the nurse is writing that she's evaluating the patient at such-and-such a date at such-and-such a time, can I use that date?
Answer 8: No. It has to be the physician, the PA, or the APN who has face-to-face
contact with the patient.
Question 9: Hi there. I have a question about provider contact time. You know, this is
becoming more and more complicated instead of becoming clearer, as far as I can see. Can you define substantiating documentation of face-to-face contact?
Answer 9: That would be an exam.
Question 9: So we have a provider start time, date, and time, and we document that.
So then as long as there's an exam in the electronic medical record, then that works? Because you're not saying that the exam has to be timed.
Answer 9: Correct.
Answer 9: Correct.
Question 9: Okay.
Answer 9: What they want is the initial provider contact time that's going to be
documented. Ideally, your chart is going to say, “initial provider contact,” and then the physician times that, or that's timed by – it can be a nursing documentation, but that initial provider contact is timed.
And then substantiating documentation will prove that the physician actually saw the patient and has documented an exam in the record. But ideally, with your initial provider contact time, it needs to be something that describes the doctor walking in and seeing the patient, so be careful on your verbiage. There's a lot of problems with the CDAC with how that's interpreted, so you have to think of it as a third party is going to interpret that and say if it's start time and it doesn't say provider start time, then somebody's going to say start time of what?
So just think of it as the physician physically seeing that patient and making it very clear to a third party.
Answer 9: Yes. And just to add on to that, it has to be someone who is – you have to
look at it as if there is someone reviewing your record, which the CDAC is doing, who is unfamiliar with your medical record, your electronic record, who can look at that documentation and ascertain from it exactly when the physician – what time the physician and the patient had direct contact because we can't – or the CDAC can't, I should say – know what something means within the confines of your hospital. It has to be clear to the
untrained eye, to someone who doesn't know your medical record as well as you do.
Answer 9: And I'll add on to that as well that the assign time – so if a physician is using
an electronic tracking board and assigns himself to the patient, that's not going to describe an initial face-to-face contact with the patient. And so, those times, if you're abstracting those, and then there's another time in there where the physician is being seen by the patient and documented, then that time is going to cause a mismatch.
Question 10: Hi. I have a question regarding the pain medication also. It just seems that whole guideline with regards to any oral, parenteral, or the nasal medication given we should automatically say “no” to are in – if the patient got the parenteral as an adult in our ER, it seems very counterintuitive, because if we gave them an aspirin in the ER it doesn't count because we have to give them parenteral.
And the other issue I have is if a patient is on 81 mg of aspirin – for cardiac and stroke prophylaxis, say – it's not really a pain medication, and I should not be penalized if we did the right thing by giving the parenteral even though that 81 mg aspirin is oral.
The whole way you have that one set up, I think, is counterintuitive to its purpose.
Answer 10: Well, I think the purpose of the measure is to make sure that there's nothing
that's going to influence the physician's decision to give that pain medication in a timely manner.
With the inability to – I guess, they have to do a blanket exclusion. They have to say any analgesic medication given prior to arrival is going to nullify the measure because that could have an influence. And these are written by the expert panels, and they say we don't want anything that's going to obscure the physician's decision.
So, of course, 81 mg of aspirin the day before the patient arrived to the hospital within 24 hours is not going to make a decision on that physician, but the experts felt that they need to eliminate everything so that there wouldn't be any confusion.
Question 11: Thank you. We were validated for the second quarter 2013 for ED- Throughput, and we have a T-sheet supplemental form, and there's an initial exam time at the top page. And many times the physician will leave that blank, but they'll sign the bottom of the form with a date and time. Now when we sent – when we created this form, we sent it to QNet, and they said that any time that initial evaluation time is blank, it would be
undetermined because you don't know when the patient – or when the physician was signing the form or seeing the patient.
So we had a case where that was left blank, the service date that's typed in at the top was, like, January 1 or something, and then they signed it
January 2nd because it was a patient that went from past midnight. So we put this as undetermined, and CDAC put in the time of the signature and date at the bottom.
So we really don't know where to proceed with that. We did an educational review, and they agreed with the CDAC without any explanation regarding the crossover of date of service and the signature time and the fact that it was left blank. And what if they did put a time up there, but then the signature date and time was different? I don't know where to go with this going forward.
Answer 11: Let me just say that on the T-sheets, on this example on slide 21 – time
patient care initiated by licensed independent provider – we actually talked to the company and asked them to change that, and they did that for us so that that would fall within the measure.
The physician just needs to time that form. I agree with what you were told: if it's timed and dated at the bottom, that could be when the physician has finished seeing the patient and he's dispositioning his record.
We had another instance where one of the facilities was putting a time stamp kind of on the sheet sideways, and that really couldn't be defined as when the provider saw the patient. We didn't know if that was when the chart was put together, or whether it was actually when the patient was seen by the provider.
So basically, the physician or the licensed independent practitioner needs to time that record at the top to say that is when they were initially seen.
Question 12: Yes. I'm currently being validated for outpatient. My question is this: over
the four quarters, do I need to have, each quarter, a score of greater than 75 or equal to; or is it a composite score for the whole four quarters in that if I miss one quarter less than 75, I will fail for that year?
Answer 12: No, it's a composite score. We take all four quarters into consideration, and
then at the end of the cycle the confidence interval is applied, which
typically will raise your score somewhat. So if you had a bad quarter, so to speak, and you needed to recoup in the other three quarters, that's certainly doable.
Question 13: Yes, I had a question about the last known well time. If the physician, the
ED physician, puts in a time or may say, “this a.m.” or not a specific hour and date, but yet the ER nurse puts in a time that is a specific hour and date, say a 2-hour window or an hour and 45 minutes or whatever, so what time do you use? The physician is not specific, but the nurse is. So what's the last known well time for that record? Do you use the nurse time that is specific, or the physician time that is not specific?
Answer 13: You're going to want to use the specific time, and that's the idea of the hierarchy is that if the neurologist, admitting physician, emergency
department physician, nurse, and EMS. So if someone has documented a specific time, you're going to use that through the hierarchy. If there are two times that are specific, you'd use the earliest time.
Question 14: Hi. I also had a question about the last known well. It's confusing at times
because sometimes you have a last known well of, say, last night at 8 o'clock, and then someone explained to me that the last known well is right at onset. So I just wanted some clarification of what time do you take for the last known well: right before the symptoms start or, like, hours before if both times are given?
Answer 14: No. The idea with last known well is that the patient's onset of symptoms
arrived right at that time, so that's going to be the last known well. You can give medication for clot-busters based on that time if the patient arrives to the emergency room quick enough and has the CAT scan done to make sure they don't have an intracranial hemorrhage. The thought process is it needs to be when the patient had the first onset of symptoms.
Question 15: Yes. I had a question about the ED departure time and the observation. I
understand that we're now supposed to use the time for the observation order as the depart time, but our usual observation orders end up being on, like, the inpatient side. Do we use the disposition time to admit, or if they don't say observation in the ED record, do we just pretend like it's not an observation?
Answer 15: If you have no observation order in the ED record, then you're going to
select the ED discharge time as when the patient actually leaves the emergency room.
Question 16: All right. My question/comment is related to initial provider contacting date and time. In the definition it's asking for the initial contact time, but
whenever you don't have that time documented, sometimes within the body of the provider note we'll see a re-check at, say, 14:25. And so, the
information I got back as an educational comment from the CDAC is that we would take that re-check time, but that's not the initial time the patient was seen by the provider.
Is there any plan to add clarification related to that to these definitions?
Answer 16: No. There's not really any plan to add clarification, and the reason that time
is being selected is that in the documentation when it's observed by the third party, the CDAC, they're seeing that that is the first time documented of a face-to-face contact by the provider. They're unable to tell from your record then that the patient was already seen by the doctor, and this is a re-check. To them, they see that as the initial provider contact time.
Question 17: Thank you. I actually have two questions related to the exam time and the
discharge time. At our hospital we have an ED event log, which, I guess, is kind of like your T, but the actual exam is in the progress notes, not on a specific paper.
But on the event log it says, “MD begin exam” and then it'll have “MD end exam” times. And then you can look in the progress notes and see where the MD has done the assessment. Now the progress notes –
Answer 17: And that –
Answer 17: I was about to say and that all sounds good so far. Go ahead.
Question 17: Right. I normally – because the progress note is usually written sometimes
10 or 15 minutes later and that's the note time they put, I usually do the “MD begin exam” time.
Answer 17: Correct.
Question 17: Okay. And not the note. But sometimes they will not put the “MD begin
exam,” but they'll do the “MD end exam” time. And that time is usually earlier than even the progress note time. So I use that “end exam time.” Is that correct?
Answer 17: No.
Answer 17: That's not going to be abstracted as initial provider contact. You're going to
want to use UTD in that instance where you're unable to see when the physician initially saw the patient.
Question 18: Hi. I have two questions. One is on OP-20. Our electronic record has time
seen, and it's in the body of the exam. Is that acceptable?
Answer 18: It would be preferred if it said, “time seen by physician.”
Question 18: But it is acceptable if it's in the body of the physician's documentation on
the assessment, right?
Answer 18: Yes, it should be.
Question 18: Okay. And then my second question is on OP-21. If a patient, an adult
patient, comes into your emergency room and is triaged and given Tylenol, you automatically exclude them from the OP-21 because the Tylenol was given, correct? And if they were later given morphine but initially given Tylenol, then you would exclude them from the measure, is that correct?
Answer 18: That's correct. The pain medication needs to be given parenteral for an
adult.
Question 19: Thank you. This is a comment on a question that was asked earlier about
ketamine administration for pain management. We submitted a question to QualityNet and the question reference number was 140218-000151 with this same exact situation, “If ketamine was administered, could that be counted as pain medication?” And our reply was, “Yes, if it was
administered in the ED by an appropriate route, you may abstract ‘yes’ to pain medication and abstract the time that relief pain medication was administered.”
So I just wanted to make that comment because I believe you were going to investigate further and get back to us.
Answer 19: Okay. Thank you.
Answer 19: Great. Thank you.
Question 20: Yes. I have a question about the clarification on the pain management. If I
have a patient that comes through the ED that takes hydrocodone at home PRN, and we do give them pain medication in the ED when they come in, I
would mark “yes” and use that time that they got the pain med in the ED? Is that correct? Because it was PRN not –
Answer 20: Correct. For a PRN medication there has to be documentation that the
medication was given. So if the home medication list has it listed as PRN but no documentation that they received that medication, then that patient is available for the measure.
Question 21: I have a question about the initial provider contact. We have OB patients
that present to the ER, and the ER physician doesn't actually see them. They're triaged through the ER to the OB department, and the OB nurses do their exam. Is that the time of exam?
Answer 21: That's a great question. I'm glad you brought that up. The way the
measure is written is that it needs to be a licensed, credentialed provider. So for OB patients, that's a very common practice in the emergency room for a patient to come in through triage and go, depending on how many weeks pregnant they are, they go up and be observed under the OB department with fetal heart tones and such.
And so the licensed – the OB nurse needs to be credentialed by your
hospital, and that just means that they're licensed or credentialed to see the pregnant mother, and that is included in the OB or the ED visit. So if that patient comes in and has an E&M code and never is seen by the ED physician, they still stay within the measure. And your initial provider contact time is going to be when that patient is evaluated by the credentialed OB nurse.
And now as far as a discharge time goes, if that patient leaves the OB department and the nurse in the OB department documents its discharge,
the patient does not go back through the ED, then that's going to be your discharge. If the – the idea is the patient's being checked out for
pregnancy, but if she is there for another issue and they go back down to the ED again, then their ED discharge time will be when the patient is discharged from the ED, and your initial provider contact will still be when the patient was seen by the OB physician and not the ED physician.
Question 22: I have a question about last known well. Our physicians in the ER will write
that they were last known well 30 minutes ago. Is it acceptable to take and subtract that time from their arrival time if that's documented? Say, they arrived at 2:30, and you put 2 p.m. Is that acceptable?
Answer 22: Yes, that is acceptable.
Question 23: Oh. Thank you. I had a question concerning provider contact time. It
sounds like a lot of other people do, too. Under the slide [19] “Improvement Suggestions, Documentation by Nurse or Other Party”: in the past we had paper records, and I knew that I could use the nurses' progress note documentation of provider first contact if it was the earliest time. Now we also have an electronic tracker, and sometimes I will see provider in room documented by a nurse, and it'll be the earliest time. And I wondered if – on the electronic tracker – if that time is the earliest and it says, “provider in room” or it indicates that the patient is being seen by the provider, can we take that as the earliest time, even if it's not documented by the doctor, the PA, or the nurse practitioner?
Answer 23: Yes. Documentation of provider contact time doesn't have to be done by
the provider. It's perfectly fine to use documentation done by the nurse or the scribe that the physician is with the patient, and “physician in room” is an acceptable terminology.
Question 24: Yes. Hi. I'm from St. Charles Hospital. How are you?
Answer 24: Fine, thanks. How are you?
Question 24: Good, good. I'm concerned about the last known well here. The thing is, is
that if the neurologist who in our hospital we deem very highly on their opinion, if they are saying that the last known well is such-and-such a time or maybe unknown, unable to determine, then why are we using if a nurse or an ED physician is documenting a certain time that may be inconsistent with the neurologist, and if the neurologist feels the patient wouldn't be qualifying for TPA?
There are discrepancies, and in Midas when we entered the data, it could come up as an OFI if it's not within that time frame. I'm just curious because it is saying the hierarchy here is the neurologist.
Answer 24: The neurologist who has documented the last known well time. So if – of
course the medical decision to give thrombolytics isn't going to be based upon the nurse's decision of when the last known well is. It's going to be based on the physician in the emergency room.
But what the measure is trying to find is what the last known well time is, so that's why you're looking at a hierarchy. If it's not documented by the
neurologist or the admitting physician or the emergency room physician, they're trying to abstract a time from the record that's documented when the last known well was. But that's not going to base your medical decisions upon thrombolytics for that.
Question 25: Thank you. I've got a question also with regards to stroke, last known well,
and then neuro say something slightly different, and then even the ATP may say something different as well.
So what my question is, is how would the CDAC – for example, if the neurologist documents a specific last known well but the note itself is not identified as being a neuro consult, but we know that Dr. Smith is our
neurologist, and therefore, we know that the neurologist said the last known well was such-and-such a time. What I don't understand is how would someone in the CDAC or an outsider viewing the chart know that I was using the time off that neuro note? Because we know that that's the neurologist if it's not identified as a neuro note, say, over the ED time that was documented.
Answer 25: Well, we do have the CDAC on the phone with us today. They were able to
help us out with the webinar today, so let me go ahead and turn that over to Trudy at the CDAC, and she can answer that question for us.
Answer 25: All right. Thank you. We would have to actually see that it's a neurologist
in order to follow that hierarchy. But if your nursing documentation is in the ED, we wouldn't follow that over any other physician documentation. Is your ED – are you referring to an ED physician or ED nursing?
Question 25: The ED physician says they came in at – I mean their last known well was a
certain time, and then the neuro physician comes in, sees the patient, and documents a different time, for example, and it's in a note. It's not identified as a neuro consult, but it's our neurologist. There's no reference to the nurses' documentation. I'm not including them. I'm just saying the neurologist's documentation of last known well is higher than the ED
physician's documentation of last known well. So when you as an outsider don't know that John Smith is the neurologist, and I'm using the time off
John Smith's note, and it differs from what the ED physician said, then I don't know how you guys would recognize why I chose that time over the ED time.
Answer 25: You're correct. I don't think we would be able to determine because if we
don't have documentation that's actually the neurologist, we would go with the earlier time.
Mollie Carpenter: Okay. Thank you. This concludes our program for today. I'd like to thank all of our speakers and participants for the valuable information and
questions you provided. We hope you have heard useful information that will help you in your Hospital Outpatient Quality Reporting Program.
Please remember that you will not receive the program evaluation survey for the CE certificate today. If we did not get to your question, please use the question and answer tool located on www.qualitynet.org. A Hospital OQR subject matter expert will send you a timely response.
Thank you again, and enjoy the rest of your day.
END
This material was prepared by FMQAI, the Support Center for the Hospital Outpatient Quality Reporting program, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). The contents presented do not necessarily reflect CMS policy. FL-10SOW-2014FS4T11-4-369