Metrics Definition - Discharge Documentation Content
Discharge Documentation Content Norm
Connect Care documentation norms relate to meaningful use expectations respecting the format, structure and content of effective summative documentation in Connect Care. In the case of discharge documentation:
A Discharge Summary should be entered to Connect Care and appropriately signed for all patients leaving a facility without expectation of return.
Provincially standardized templates (either "discharge summary", "inter-facility transfer summary" or "deceased summary") should be used to ensure that all expected elements are contained, with sections with standardized headings appearing in a standardized order.
Required content includes specification of primary care, discharging attending and any ongoing consulting prescribers; together with standardized elements of a transition of care plan.
Further details of the relevant meaningful use norms are summarized in the Connect Care Clinician Manual:
Discharge Documentation Content Metrics
Evaluating the quality content of discharge documentation is currently limited to detecting the presence of structured data elements expected within expected summary sections. In addition, note properties (e.g., length, use of copy-paste, structured vs free-text vs dictated content, etc.) can be reported to provide additional feedback to interested groups.
Discharge documentation that addresses key content requirements (e.g., a clear transition of care plan), may be reflected by use of standardized building blocks that more commonly appear in compliant documents.
Primary Care Provider Inclusion Metric
Proportion of discharged patients where the patient's Primary Care Provider (PCP) is entered or reviewed and included in discharge documentation.
Readmission Risk (LACE Index) Inclusion Metric
Proportion of discharged patients where the patient's discharge summary includes primary care followup recommendations keyed to the LACE Readmission Risk Index.
Workflow
Encounter Documentation Norms and related Workflows are described in the Connect Care Clinician Manual.
Primary Care Provider Review
The entry, review and revision of patient associations with primary care providers or services (PCP) is normally a mandatory administrative task. Inpatient registration clerks gather this information at every presentation of a patient to hospital. If provisional, it is revisited when more information becomes available. Admitting, registration and ward clerk check-lists alert to missing PCP information in Emergency Department and Inpatient contexts.
In addition, inpatient providers can update PCP information at any time during an encounter, using a variety of tools:
Inpatient Chart Storyboard - hover and select-to-edit to add, remove or change a PCP.
Inpatient Chart Care Team Activity - review and click-to-edit functions.
Inpatient Chart Sidebar - discharge planning and care team views support click-to-edit.
Patient Lists - double-click to edit-in-place for AHS-developed provider information columns.
Interactive Charting - provincial standardized templates for admitting, consulting and discharge documentation all pull in the PCP as click-to-edit interactive text.
Patients using the MyAHS Connect patient portal can submit a request to have thier PCP information updated in Connect Care.
It is extraordinarily rare for prescribers to encounter a chart where PCP validation has not already occurred. Accordingly, prescriber responsibilities focus on updating this information when patients lacking a PCP secure an association during an admission, or inform of a changed association just prior to discharge documentation workflows.
Tippy: Routing Documents to External Systems When There is No Primary Care Provider
Tippy: Adding or Updating Referring and Primary Care Providers in Clinic Schedule Lists
LACE Index for Readmission Risk
Plentiful evidence shows that patients with multiple comorbidities, frequent emergency room visits or other frailty indicators are more likely to present for readmission to hospital within a short time following their last discharge. Many of these readmissions are preventable, mostly through anticipation, communication and provision of risk-aware post-discharge supports.
AHS uses the "LACE readmission risk index" to stratify patients into those who are at low, moderate or high risk for early readmission. The index considers the patient's length of stay, admission type, comorbidities and frequency of emergency room visits.
The LACE Index is automatically calculated using data from the inpatient chart. It is presented in multiple inpatient workflows, always in an "interactive" format such that the user can click on the Index to get a popup explanation of the index value, interpretation and derivation. Users can immediately appreciate if the index may be skewed by lack of comorbidity information in problem lists or medical histories and this data can be added or revised directly from the presented information.
LACE Index values are then used to generate standardized text within discharge summaries that use provincially standardized templates. PCP followups are recommended within a month for patients at low risk, within 14 days for moderate risk and within 7 days for high risk.
Data
Primary Care Provider
Epic Systems support identification of multiple primary care providers for each patient. This is consistent with American practice where, for example, an internal medicine physician can be a primary care provider for adults. Canadian practice differs in that specialists can bill for services only if consulted by a primary care provider. The Alberta norm is to associate a single PCP (provider or service) with each patient. Specialists who provided long-term follow-up for a patient's specific disorder(s) are label "Principal Care Providers" and can be designated within Connect Care. Use of a common abbreviation is unfortunate. The PCP used in Alberta is a Principal Care Provider of Type = 1 (General).
The single PCP norm is being formalized through Alberta's emerging Central Patient Attachment Registry (CPAR). Connect Care PCP information can update Alberta's Electronic Health Record (Netcare) PCP field, but not its CPAR field (future development).
Accordingly, users and builders are expected to use AHS-approved PCP SmartTools (e.g., ".AHSPCP" SmartLink which returns the correct PCP field in the correct name format).
The currently designated PCP is stored in EPT 80150 as a Connect Care Provider Registry unique identifier.
When a patient has a PCP that is not currently in the provider registry, the preferred practice is for admitting staff to add the provider.
If an unrecognized PCP needs to be added but insufficient information exists for a valid entry, staff select "Provider Not In System" as the PCP.
If a patient has no current PCP association, staff select "Patient Has No PCP".
EPT data group 80100 contains an archive of changes to any Principal Care Provider field made during the encounter.
LACE Readmission Risk Index
The current (latest) LACE Index value (integer) is stored as a score value (HDA 30410005501 AHS LACE READMISSION INDEX). This score is then interpreted by rules to generate conditional text inserted into discharge and other documentation. The Risk of Readmission categories for the score include Low: 0-4; Moderate: 5-9; High: ≥ 10 and these trigger different primary care follow-up recommendations post-discharge.
Use of the Connect Care automated LACE Index and associated discharge follow-up recommendations is reflected by use of any of the following SmartText (ETX) objects at any point during an inpatient encounter:
AHS IP POC DC FOLLOWUP MIN [29221]
AHS IP POC DC FOLLOWUP MOD [29220]
AHS IP POC DC FOLLOWUP MAX [29219]
AHS IP POC DC SUPPORTS MOD [29223]
AHS IP POC DC SUPPORTS MAX [29222]
AHS IP BASIC DISCHARGE SUMMARY [15785]
AHS IP TEXT BLOCK LACE INDEX [3042922068]
A call for any of the above ETX records within an encounter can be used to credit the encounter with certain use of LACE in discharge documentation.
More information about LACE-related build objects:
Metrics
Primary Care Provider Inclusion Metric
Description
Proportion of discharged patients where the patient's Primary Care Provider (PCP) is entered or reviewed and included in discharge documentation.
Denominator
Number of Patient Encounters where:
Inpatient (EPT 10110 = Inpatient) AND
Discharged (EPT 10115 = Discharged) AND
Admission effective instant (ADT 59 = User specified date of admission)
Numerator Sub-metrics
Has valid PCP: Number of Patient Encounters from denominator where:
Current PCP (EPT 80150) IS NOT NULL, AND
Current PCP (EPT 80150) IS NOT EQUAL TO "Provider Not In System [E9999999]"
Current PCP (EPT 80150) IS NOT EQUAL TO "Patient Has No PCP [197780]"
Has non-registry PCP: Number of Patient Encounters from denominator where:
Current PCP (EPT 80150) EQUALS "Provider Not In System [E9999999]"
Has no PCP: Number of Patient Encounters from denominator where:
Current PCP (EPT 80150) EQUALS "Patient Has No PCP [197780]"
Calculation
Numerator DIVIDED INTO Denominator expressed as PERCENTAGE rounded up to nearest integer percentage point
Filters
Hospital Speciality Service: EPT 18886 - CATEGORY - (e.g., General Internal Medicine [106])
Hospital Unit: EPT 18880 - CATEGORY - inpatient unit/ward (e.g., EDM UAH WMC 5D4 GIM [101094229])
Hospital Facility: EPT 18883 - CATEGORY - (e.g., EDM WMC University of Alberta Hospital [101094])
Analytics Definition
LACE Index Inclusion Metric
Description
Proportion of discharged patients where the patient's discharge summary includes primary care followup recommendations keyed to the LACE Readmission Risk Index.
Denominator
Number of Patient Encounters where:
Inpatient (EPT 10110 = Inpatient) AND
Discharged (EPT 10115 = Discharged) AND
Acute patient status (EPT 10135 = "Acute") AND
Encounter link (EPT 20330) to Encounter Notes list (HNO) INCLUDES an item with
Note Type (HNO 34033) = "Discharge Summary [5]" AND
Note Status (HNO 17100) = "Signed [2]" or "Cosign Needed [9]" AND
Hospital Discharge Date and Time (EPT 18855 and EPT 18856) = User specified date of discharge
Numerator
Number of Patient Encounters from denominator where:
Discharge Summary Note (HNO 34033) SmartText Record Identifiers (HNO 34906) INCLUDE 29219 OR 29220 OR 29221 OR 29222 OR 29223 OR 15785 OR 3042922068
Calculation
Numerator DIVIDED INTO Denominator expressed as PERCENTAGE rounded up to nearest integer percentage point
Filters
Hospital Speciality Service: EPT 18886 - CATEGORY - (e.g., General Internal Medicine [106])
Hospital Unit: EPT 18880 - CATEGORY - inpatient unit/ward (e.g., EDM UAH WMC 5D4 GIM [101094229])
Hospital Facility: EPT 18883 - CATEGORY - (e.g., EDM WMC University of Alberta Hospital [101094])
Analytics Definition
Limitations
Primary Care Provider Inclusion Metric
AHS standard operating procedures check and re-check patients' PCP at every encounter with AHS facilities, including laboratory, clinic and diagnostic imaging visits. This tends to a higher rate of validation that is possible for other information systems. Moreover, Connect Care clerks can be aware of and use information appearing in Netcare as a PCP or CPAR identification.
Connect Care prioritizes patient-reported information over what might appear in the Netcare EHR (which may be outdated) when reviewing and revising its PCP data entry. Accordingly, patient errors or forgetfulness may affect the quality of recorded PCP data.
Connect Care providers can make changes to the PCP for a patient without this change being double-checked by registration staff. Prescribers, in particular, do not have the level of training that clerks have and so could make mistakes.
Lace Readmission Risk Index Inclusion Metric
The comorbidities component of the LACE Index calculation is sensitive to whether a patient chart complies with minimum use norms. It is essential that a patient's chronic illnesses be documented in the problem list and/or medical history sections of the chart. If a particular LACE Index seems inappropriately low, providers have opportunity to jump to problem list and/or medical history editing tools.
If inpatient problem lists or histories do not fully reflect their comorbidity burden, other dimensions of the index may still push the patient into a moderate or high risk stratum. Hospital admissions and ER visit data in Connect Care tends to be accurate within AHS zones.
Epic does not presently provide tools for performing a full-text analysis of discharge summaries. Accordingly, users may dictate or otherwise generate discharge summaries without using LACE SmartTools (e.g., ".LACEINDEXP" to insert into documentation) or provincial documentation templates containing those tools. The metric will under-estimate the true rate of readmission-risk-aware discharge documentation.
This metric is likely to generate very low percentages (likely <25%) until education, change-management and feedback motivate more users to use standardized templates and/or SmartTools to generate discharge summaries that take advantage of structured chart data.
Reports
Radar Dashboards
Reporting Workbench
Slicer-Dicer
Components
Summative documentation content is supported in Connect Care (Epic) with standardized templates that make use of AHS-validated standardized components, many further described in the Builder Handbook.