Problem List and Comorbidity Notices Webex

Justine Carr

John Unterborn

Karen Hughes

January 2013

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Problem List as Efficient New Source of Patient Information• The problem list is now a required part of the medical

record.– Efficient abstract at discharge– Shared among caregivers for continuity

• Physicians/LIPs must update and maintain this list.– Enter problems as they appear– Edit status at discharge– If you are going (or have gone) off service, you should still add

the problem, if it is accurate

• Problems should appear in 3 places– On the list AND in the daily note AND in the d/c summary

Why is the Problem List important?

Problem

List

Alerts all hospital care

givers of new

problems to modify

care plan

Alerts care givers

post discharge of

problems

Alerts care givers

on subsequent

admission

Ensures capture of

patient complexity for

coders (affects risk

adjustment and payment)

Achieves requirement

for Hospital’s

Meaningful EHR Use

Certification

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When to Add Problems to Problem List?

Admission

Automated

Trigger

Notice

New clinical

issue

Transfer

serviceDischarge

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What Problems Should Be Added?

• Diagnoses– Reason for admission

• E.g. diabetic ketoacidosis

– Chronic problems• E.g. atrial fibrillation; hypertension; COPD

• Comorbid Conditions– Present on admission

• E.g. urinary tract infection; hypernatremia

– Acquired during hospital stay• E.g. acute renal failure

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Who adds problems to the problem list?• Last year, Nurses added problems to the

problem list.• This year, Licensed Independent Practitioners

(MD, DO, NP, PA, Midwife) need to add problems to the problem list and manage the problem list to insure completeness as part of the discharge information for the next care giver.

• Next year, we are asking Meditech to improve information flow between problem list and nurse care plan

Automated Problem List assistance

• Lab-driven alerts for selected diagnoses Comorbidity Noticeo This is a developing piloto Initial prompts: renal failure, respiratory failure, DKAo New prompts (1/31/13): acidosis, alkalosis,

hypernatremia, hyponatremia, pancytopenia

• Electronic “Page one” at discharge to review and update the problem list

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Ensuring Documentation Completeness

Clin

Doc

Special

ist

•Review

charts

periodicallyComorib

idity

Alerts

•Real time

surveillanceCode

rs

•Final check

at

discharge

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Automated assistance for Problem ListLab test exceeds

threshold

• Alert sent to

Ordering and

Attending MD

• My Notices

• Comorbidity

Report

MD views Alert

notice

• Problem

added if

accurate

statement.

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Comorbidity Alerts: Dec 10, 2012ICD 9 Code

ICD 9 Code Description Clinical Triggers Meditech Message -

250.13DKA DIABETES WITH KETOACIDOSIS TYPE I, UNCONTROLLED

Glucose > 300 mg/dl AND Anion Gap > 12

This patient has hyperglycemia (glucose > 300 )and widened anion gap consistent with DKA

250.12DKA DIABETES WITH KETOACIDOSIS TYPE II, UNCONTROLLED

Glucose > 300 mg/dl AND Anion Gap > 12

This patient has hyperglycemia (glucose > 300 )and widened anion gap consistent with DKA

584.9ACUTE RENAL FAILURE

Creatinine > 1.5 mg/dl AND Creatinine increase of > 0.5

mg/dl

This patient has a Creatinine > 1.5 and an increase > 0.5 since the last test

518.84ACUTE AND CHRONIC RESPIRATORY FAILURE

pH < 7.35 and pC02 > 50 OR pO2 < 60

This patient has hypoxemia or a respiratory acidosis with pCO2 > 50 mm/Hg

518.83ACUTE RESPIRATORY FAILURE

pH < 7.35 and pC02 > 50 OR pO2 < 60

This patient has hypoxemia or a respiratory acidosis with pCO2 > 50 mm/Hg

518.81CHRONIC RESPIRATORY FAILURE

pH < 7.35 and pC02 > 50 OR pO2 < 60

This patient has hypoxemia or a respiratory acidosis with pCO2 > 50 mm/Hg

Meditech Message – This alert has been automatically generated from pre-set laboratory thresholds but requires clinical correlation

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Comorbidity Alerts: Jan 31, 2013ICD 9 Code

ICD 9 Code Description Clinical Triggers Meditech Message

276.2 ACIDOSIS pH < = 7.35 This patient has pH<=7.35

276.3 ALKALOSIS pH> 7.47 This patient has pH> 7.47

276.0HYPEROSMOLALITY and/or hypernatremia

Sodium >150This patient has hyperosmolality or a Serum Sodium result > 150.

276.1HYPOSMOLALITY and/or hyponatremia

Sodium <130This patient has hyposmolality or a Serum Sodium result < 130.

284.19 PANCYTOPENIAHct < 30% and WBC

<4K and Platelets <100K

This patient has anemia, leukopenia and thrombocytopenia.

Meditech Message – This alert has been automatically generated from pre-set laboratory thresholds but requires clinical correlation

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Comorbidity Notices for Multiple Patients > Click on notice to review

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pH <7.35 triggers Acidosis

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Acidosis w/comment detail > Save

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Acidosis now appears on Problem List

Reconciliation of Problems at Discharge• Problems pull into the Electronic Page 1

– Edit/update the problem list at discharge

• Benefits– Up to date current list is shared with patient and next

provider of care as required by Meaningful Use– Problem list is current if the patient is re-admitted at a

later time

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Click Document to Begin the E-Page 1

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Click New in the footer

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Click Discharge Referral

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Referral Opens, Problems pull into E-Page 1

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Problems from summary panel pull in and the display will

say “Entered”

Click Problem field to view/edit/update

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To Update the List, Click Edit in Footer

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If a problem is no

longer active,

click on EDIT.

Click on Status to change ARF to Resolved > Save

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This notice was automatically generated from a pre-set lab threshold and requires clinical correlation.

This patient has a creatinine greater than 1.5 or an increase of greater than 0.5 mg/dl since last test

Problem List Updated E-page 1

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Click OK to return to the E-page

1 and enter additional

information

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View of completed page 1

prior to entering your PIN to

Sign/Save

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Questions or Suggestions

• Contact:– VPMA at your hospital– Justine Carr, MD justine.carr@steward.org

– Karen Hughes karen.hughes@steward.org