In September of 2010, CMS issued FAQ 10126 giving providers options on counting patients in numerator and denominator of Meaningful Use Measures. However, guidance on criteria and processes by which EHR software would be certified were issued in the Federal Register prior to this guidance (January of 2010), and have not been re-issued since.
So … does your standard EHR automatically know what decision you have made?
Action Item: Verify that the list of 12 Meaningful Use Reports providing the option for “all ED Patients” or “Observation Services Patients”, and test numerator / denominator for completeness and accuracy.
CMS has stated their desire to include in the denominator visits to the emergency department (ED) of sufficient duration and complexity, that all of the Meaningful Use objectives for which the ED is included would be relevant. Giving hospitals the option to select between “All ED Patients” and “Observation Services Patients” seems to recognize impracticalities on counting ED patients who may move quickly in and out of the hospital and may not receive a level of services that would qualify the hospital under meaningful use, by limiting numerator and denominators to patients actually receiving ED services. Although this guidance helps, our subscribers have asked us to research a few additional questions to help stay in compliance.
- Question 1: Do we include all inpatients or only inpatients admitted through the ED?
Choosing Observation Services Method has no impact on defining how Inpatient visits will be measured. It does define a population of patients (ED patients who have been admitted to IP wards), for whom the provider must include all visits and activities in numerator and denominator. Since all these patients should be included in inpatient reporting (independently of Observation Services Method) the practical matter here seems to be the requirement (and opportunity) to include documentation of services performed during the ED portion of the encounter for those patients.
- Question 2: For the observation patients, do we include all observation service patients, or only those who present through the ED?
In providing a choice of using Observation Services patients (as a subset of ED Patients), CMS seems to be reacting to some of the practical problems of reporting on a broader, more volatile patient population of everyone who presents to the ED. We do not think their intent is an across-the-board substitution of Observation Services Patients for ED patients, so the safest option seems to be making sure your reporting correctly identifies those Observation Services Patients who initially presented to the ED, and as in the prior question, accounting in the numerator for all documentation occurring in the ED setting on those patients. Any Observation Services patients coded with a Place of Service Code other than 21 or 23 (Inpatient or ED) would be excluded from your numerator / denominator (except for those initially presenting through the ED).
- Question 3: How does the selection of Observation Services Patients impact Clinical Quality Measure calculations?
- First, the language of FAQ 10126 addresses numerator and denominator of Meaningful Use Objectives explicitly. In the Final Rule for EHR Incentives, CMS consistently lists those specific Objectives, and identifies Clinical Quality Measures separately.
- Secondly, the Clinical Quality Measures contain specific calculations, data elements, and exclusion rules via independently-published HITSP specifications.
- Finally, in a separate related FAQ # 10883 issued on December 22, 2011, CMS answers a question regarding CQMs ED-1, ED-2, and Stroke-4, on how should hospitals define an Emergency Department patient since the UB-04 data set referred to in the HITSP specifications no longer provides this information? In this FAQ, CMS recommends that hospitals use the data element 'ED Patient', defined as any patient receiving care or services in the Emergency Department (without comment regarding Observation Services Method).
- Therefore, while none of these statements are definitive, we believe the trend is to isolate Observation Services Method calculations to Meaningful Use Measures, independently of Quality Measures.
So, the bottom line is that it is probably prudent to test following 12 reports in your Certified EHR to validate that they are correctly counting ED patients consistently, based on your decision on using Observation Services Method:
- CPOE
- Record Demographics
- Problem List
- Maintain Active Medication List
- Maintain Active Medication Allergies List
- Record Vital Signs
- Record Smoking Status
- Provide patients with an Electronic Copy of their Health Records Upon Request
- Provide Patients with an Electronic Copy of their Discharge Instructions Upon Request
- Use Certified EHR Technology to Identify Patient-Specific Education Resources
- Perform Medication Reconciliation
- Provide Summary Care Record for each Transition of Care
All other reports would fall under either Clinical Quality Measures, or require a Yes / No attestation (which would be probably be independent of your ED patients), or explicitly exclude ED patients in their definition.
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