Every hospitalist is familiar with core measures, regardless of whether they go by that name or by “best care measures,” “hospital quality measures” or something else. In a nutshell, these measures reflect evidence-based care processes that are closely linked to positive patient outcomes.
Hospitals that reach certain benchmarks of compliance with core measures are reimbursed more from the Centers for Medicare and Medicaid Services (CMS) and other payers. Yet, while the reporting of core measures is mandated by CMS, there is no funding for collecting the data, which can be quite time-consuming and expensive, and involve multiple staff members. At the hospital (and health care system) where I work, we have developed several electronic medical record (EMR) tools to help with data collection and compliance, including admission and discharge order sets, nursing protocols, and macros.
According to CMS guidelines, every hospitalized patient needs to be screened for cigarette smoking, alcohol or substance abuse, and influenza/pneumonia immunization. To improve compliance with these core measures, we created a series of protocols for nurses to assess each patient's need for immunization or substance abuse counseling. As part of the admission process, the EMR prompts the nurse to ask the patient several questions.
For example, during flu season, the EMR prompts asking the patient about contraindications to immunization, such as whether s/he has a history of developing Guillain-Barré syndrome within six weeks after receiving a previous influenza vaccination, whether s/he is allergic to eggs or vaccine, or whether s/he has had a bone marrow transplant within the last six months. If the patient has no contraindication, influenza vaccination is offered, which the patient can accept or refuse.
A similar, though more complicated, protocol is used for pneumococcal vaccine. If the patient is over 65 years old, s/he is asked if s/he has had the vaccine. If not, s/he is then asked if s/he had a bone marrow transplant within the last six months, got radiation or chemotherapy within the last two weeks, or has an allergy to the vaccine. If there are no contraindications, the patient is offered the vaccine. If the patient has had it, but it has been more than five years and there are no contraindications, s/he is offered re-immunization. If the patient is younger than 65 years, the nurse checks a list of high-risk conditions to see if s/he is eligible for the vaccine. Or, if the patient was previously vaccinated and it has been more than five years and he or she is immunocompromised (such as by having a damaged spleen, sickle cell disease, HIV infection or cancer), s/he is offered re-immunization as long as there are no contraindications.
The EMR guides the nurse step by step through this somewhat convoluted protocol, finally leading him or her to the decision to immunize or not. The data the nurse enters along the way are saved and used to document compliance with the immunization core measures. By making this process automatic as part of the admission process, our compliance with these measures has improved significantly.
The Surgical Care Improvement Project (SCIP) includes time-sensitive core measures that must be met postoperatively and that can be easily missed. We created a macro for our EMR that asks physicians a series of questions about postoperative use of antibiotics, Foley catheters, deep venous thrombosis prophylaxis, and beta-blockers. (See sidebar on next page for more detailed information.)
After the questions have been answered, a paragraph like this is generated and entered into the physician's progress note:
“The Foley catheter has been continued beyond post op day 2 for open sacral wound with incontinence. Antibiotics are being given as there is evidence of active infection. Venous thromboembolism prophylaxis is contraindicated because of active hemorrhage. The patient was not restarted on his or her beta-blocker because of hypotension.”
This macro serves to both remind the physician to follow the core measures and helps ensure they are documented properly in the EMR.
Problem areas and discharge sets
When specific problem areas with core measure compliance are discovered, such as initiating intensive statin therapy for stroke patients, an automated alert notifies the physician. The EMR looks for patients with a stroke diagnosis who are either not on a statin or have a contraindication for a statin. When a patient who meets these criteria is found, the physician receives an alert that encourages him or her to either order a statin or document why he or she is not doing so.
Finally, there is an area on the discharge order set devoted to core measures for venous thromboembolism, acute myocardial infarction, heart failure and stroke. If a physician is discharging a patient with one of these diagnoses, he or she is required to answer a series of relevant questions. For a heart failure patient, the physician must indicate if the patient had his or her left ventricular function assessed, and if so by what means. Alternatively, the physician can select a CMS-approved reason why it was not assessed. There are also sections on patient education and diet that can be filled out with a couple clicks of the mouse.
These order sets help physicians to comply with and document core measure requirements. Following the instructions in these order sets also serves to teach physicians about the core measure requirements, making it less likely that future patients will have core measures missed. The data entered from the order sets' questions are stored in a specific area of the EMR, making abstraction of the data for reporting easier.
Core measure compliance is a complex though vitally important task. The current core measure guidelines from CMS comprise 103 documents, including a data dictionary that is 436 pages long. The specifications manual for core measures is also updated twice a year, with measures being added, modified and removed. It is difficult for practicing physicians to keep up with these requirements. By creating tools in an EMR, one can significantly improve compliance and ease the difficult task of abstracting data from the EMR, as we have at Hawaii Pacific Health.