In June, 2009,the Physician Consortium for Performance Improvement, which in part includes the American Board of Internal Medicine Foundation, American College of Physicians, Society of Hospital Medicine and the AMA Physician Consortium, published Care Transitions: Performance Measurement Set entitled Phase I:  Inpatient Discharges and Emergency Department Discharges.

Since 2003, SETMA has utilized NextGen EMR in the in-patient setting in order to complete Admission History and Physician examinations and Discharge Summaries for the patients who care we manage.  SETMA has designed and used a Daily Progress Note in our EMR as well. That project was suspended until we get an interface built between the hospital and NextGen so that daily vital signs and patient-condition data, laboratory values and medications can be automatically posted to our EM.

After reviewing the content of the Care Transitions Measurement Set, it was apparent that with a few modifications which have been made, SETMA performs all of the elements of this set.  We believe that the auditing of this performance measure by the provider at the point of service will improve that quality of care given to patients transitioning from inpatient or ER to another place of care.  In addition, the method SETMA has developed to make the elements automatically interactive with the patient’s care streamlines this process and makes it easy.

This Tutorial explains SETMA’s deployment of this measurement set and how to use it. Currently, the Care Transition Data Set contains 18 elements.  Fourteen or documentation elements and four are action elements.  Please note that this is Phase I of the Care Transition Data Set; as this set evolves, SETMA will modify this deployment to reflect those upgrades.

How to utilize SETMA’s Care Transition Audit

You will find the Care Transition Audit took by opening the AAA Home template

In the fourth line of navigation buttons, you will see Discharge. Click on this button and it launches the Master Discharge Template

The Care Transition Audit button can be found at the bottom of the screen.

When that button is depressed, the following pop-up appears.

There are eighteen data points in the Care Transition Data Set. Fourteen are elements of documentation and four are actions which are to be taken.  Once the discharge summary has been completed, If the element has been met in the patient’s record, or if the action required has been taken, two things will appear:

1. The element will appear in black fonts
2. The box next to the element will contain a “Yes” which will be in black fonts.

If the documentation or action required for an element in the Care Transition has not been completed, two things will appear:

1. The element will appear in red fonts
2. The box next to the element will contain a “No” which will be in red fonts.

To the right of each of the first fourteen elements of the data set, there is a button entitled “Click to update/review.”  When this button is depressed, it will automatically take you to the part of the discharge record which will allow you to document what is required but missing.  In that the last four elements require an action, the documentation is completed by marking the “yes” or “no” radial button next to the element.

The eighteen elements are:

1. Has the reason for hospitalization been documented?”

If the box next to this element indicates that it has not been documented, in which case a red “No” appears, depressing the “update/review” button displays the following template reason for hospitalization can be entered.

The reason for hospitalization can then quickly be added to the record.

2. “Have Discharge Diagnoses been entered?”

If the box next to this element indicates that it has not been documented, in which case a red “No” appears, depressing the “update/review” button displays the following template where the discharge diagnoses can be entered.

3. “Have the patient’s medications been updated/reconciled?

If the box next to this element  indicates that it has not been documented, in which case a red “No” appears, depressing the “update/review” button displays the following template where the medications can be updated and/or reconciled.

4. “Have the patient’s allergies been updated?” “Also, document allergies/reactions to medications.”

If the box next to this element  indicates that it has not been documented, in which case a red “No” appears, depressing the “update/review” button displays the following template where the allergies can be reviewed, updated and where any adverse reactions which took place during the hospitalization can be documented.

5. “Has the patient’s cognitive status been documented?”

If the box next to this element indicates that it has not been documented, in which case a red “No” appears, depressing the “update/review” button displays the Constitutional template of the physical examination where the patient’s cognitive status can be documented..

6. “Have pending results or test been documented?””

If the box next to this element indicates that it has not been documented, in which case a red “No” appears, depressing the “update/review” button displays the Hospital Course template where any pending or unreported tests can be denoted.

7. “Have major procedures been documented?”

If the box next to this element indicates that it has not been documented, in which case a red “No” appears, depressing the “update/review” button displays the Major Procedures template where the results can be entered.

8. “Has a follow-up care plan been completed?”

If the box next to this element indicates that it has not been documented, in which case a red “No” appears, depressing the “update/review” button displays the Follow-up Plan template where the plan can be entered.

9. “Has the patient’s progress to goals/treatments been documented?”

If the box next to this element indicates that it has not been documented, in which case a red “No” appears, depressing the “update/review” button displays the Hospital Course template where the progress to goals/treatments can be documented.

10. “Have advanced directives been completed and a surrogate decision maker selected or a reason given for not completing an advanced care plan?”

If the box next to this element  indicates that it has not been documented, in which case a red “No” appears, depressing the “update/review” button displays the Advanced Directive Detail template.

11. “Has the reason for discharge been documented?”

If the box next to this element indicates that it has not been documented, in which case a red “No” appears, depressing the “update/review” button displays the Hospital Course Template where the reason for discharge can be documented in the section provided.

12. “Has the patient’s physical status been documented?”

If the box next to this element indicates that it has not been documented, in which case a red “No” appears, depressing the “update/review” button displays the Physical Examination section of the discharge summary.

13. “Has the patient’s psychosocial condition been documented?”

If the box next to this element indicates that it has not been documented, in which case a red “No” appears, depressing the “update/review” button displays the Functional Assessment template where the patient’s psychosocial condition can be documented.

14. “Has a list of available community resources and/or coordinated referrals been documented?”

If the box next to this element indicates that it has not been documented, in which case a red “No” appears, there are two options for fulfilling the element:

A.      For those patients not being followed-up in a SETMA clinic depressing the “update/review” button displays Local Available Services template which will allow you to refer them to a local clinic.