Record Demographics and Advance Directives

1. Configuring RPMS-EHR for Meaningful Use Resource Patient Management System Record Demographics and Advance Directives

2. Presenters: Jason Loepp, RHIA HIM Director, Cherokee Nation Health Services Lisa Lyon, BSN, RN, CDE Clinical Informatics Coordinator, Cherokee Nation Health Services Toni Potts, BBA Clinical Applications Coordinator Manager, Cherokee Nation Health Services Record Demographics and Advance Directives

3. Training Objectives • Understand the MU objectives and the measures • Record the required elements (Preferred Language, Race, Ethnicity, Date & Preliminary Cause of Death) • Document Advance Directives in both Patient Registration & appropriate TIU Note Titles • Generate TIU/SSD list of titles to verify Advance Directive is associated with the correct title • Verify scanned Advance Directive documents are associated with the correct note title Record Demographics and Advance Directives

4. Record Demographics Objective and Measure Record all of the following demographics: • Gender, date of birth • Preferred language, race, ethnicity • *Date and preliminary cause of death in the event of mortality in the eligible hospital or CAH More than 50% of all unique patients seen by the provider or admitted to the hospital’s inpatient or emergency department have demographics recorded as structured data. Record Demographics

5. MU Measure Type of Measure: Rate Record Demographics

6. RPMS Reporting Logic Denominator Inclusions: COUNT: each patient HAVING: one or more face-to-face visits with the provider during the EHR reporting period Record Demographics

7. RPMS Reporting Logic Numerator Inclusions: COUNT: each patient in the Denominator WHERE: structured data is present during the EHR reporting period for each of the following data elements: Preferred language Gender Race Ethnicity Date of birth OR WHERE: a structured data element is present indicating: THAT: The patient declines to provide the data element information OR THAT: Capturing the race and ethnicity is against state law Record Demographics

8. RPMS Reporting Logic Measure Exclusion: None Record Demographics

9. Advance Directives Objective and Measure Record advance directives for patients 65 years old or older. More than 50% of all unique patients 65 years old or older admitted to the hospital’s inpatient department have an indication of an advance directive status recorded as structured data. Advance Directives

10. MU Measure Type of Measure: Rate Advance Directives

11. RPMS Reporting Logic Denominator Inclusions: COUNT: each patient HAVING: an age of 65 years or older on date of admission AND HAVING: one or more admission dates to a hospital's or CAH's inpatient department (POS 21) during the EHR reporting period, defined as Service Category of H Advance Directives

12. RPMS Reporting Logic Numerator Inclusions: COUNT: each patient in the Denominator WHERE: structured data is present indicating one or more of the following conditions: • A note title in the TIU Document Class "Advance Directive.“ • An Advance Directive value of "Yes" or "No" Advance Directives

13. RPMS Reporting Logic Measure Exclusion: • Eligible hospitals and CAHs who have no patient admissions for patients with an age of less than 65 years on date of admission during the EHR reporting period are excluded from this measure. Advance Directives

14. What HIM Needs to Know • Patient Registration Parameters for Race, Ethnicity & Preferred Language should be set to mandatory • The Underlying Cause of Death is recorded in ADT or PCC using the UCD mnemonic • Patient Registration records presence or absence of Advance Directive • Presence of an Advance Directive is recorded using a TIU note title “Advance Directive” • HIM should routinely perform a search using the SSD menu for quality control Record Demographics and Advance Directives

15. Configuration • Patient Registration parameters should be set to mandatory • Advance Directive note title must be under Advance Directive document class Record Demographics and Advance Directives

16. How-to Session • Set to mandatory the Patient Registration Parameters for Race, Ethnicity & Preferred Language • Record Race, Ethnicity and Preferred Language in Patient Registration • Record the Underlying Cause of Death in ADT or PCC using the UCD mnemonic • Record presence or absence of Advance Directive in Patient Registration • Record presence of an Advance Directive using TIU note title • Search Advance Directive note titles using SSD menu for the purpose of quality control Record Demographics and Advance Directives

17. Policy and Procedure Review Record Demographics and Advance Directives

18. How-to SessionQuestions & Discussion Record Demographics and Advance Directives