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Running head: MEANINGFUL USE EXECUTIVE REPORT AND PRESENTATION 1

Scholarly Project Proposal: Meaningful Use Executive Report and Presentation

Jennifer Dilly

Ferris State University

April 22, 2012

MEANINGFUL USE EXECUTIVE REPORT AND PRESENTATION 2

Abstract

Healthcare delivery is complex and continually changing. Part of this change includes how new

technology is being used to promote safer patient care and better patient outcomes. The following

proposal intends to outline a Scholarly Project related to the quality metrics, stroke and venous

thromboembolism (VTE), required for attestation of Meaningful Use (MU). The background related to

healthcare reform and technology is first provided. The setting for the project is explained in detail as are

the qualifications of the selected preceptor. Goals and objectives are provided along with an explanation

of activities that will support accomplishment. The major goal to be achieved includes ensuring the

facility will meet the MU requirements through use of an electronic health record (EHR). The timeline

for completion of each activity is included. An evaluation tool is provided with the intent of showing

whether the student has met or exceeded each objective.

Keywords: healthcare reform, Meaningful Use, quality metrics, technology


Scholarly Project Proposal: Meaningful Use Executive Report and Presentation

Huckvale et al. (2010) suggest that correct usage of well-established technology tools can

lead to safer and higher quality patient care. Capture of patient information and the exchange of

the information between caregivers can be complicated but ultimately quite beneficial. A

workgroup, established by the World Health Organization (WHO), has conducted a systematic

review of literature surrounding the influence of information technology (IT) on patient safety

(Huckvale et al., 2010). There is a potential for technology to increase safe patient care, however

there are still many barriers including incorrect implementation methods, improper interfaces

between multiple systems, and incorrect usage. According to Shaw (2012), a community

hospital in New Hampshire has shown significant decreases in patient readmissions, improved

door-to-balloon times, and increases in other key performance indicators by correct usage of

technology. The technology has enabled caregivers to have patient data at their fingertips, data

that can be used to track patient progress in real-time and respond immediately or even thwart an

adverse event. There is also the potential for alerting the caregivers that further actions need to

be performed for the patient yet. For this hospital, these functions are the epitome of how

technology and the data gained from technology becomes meaningful.

The government has also stepped in to ensure the use of technology and the data it

produces is meaningful. As part of the 2009 American Recovery and Reinvestment Act

(ARRA), the Health Information Technology for Economic and Clinical Health (HITECH) Act

was developed to incentivize facilities and providers to use Electronic Health Records (EHR) to

increase the delivery of safe, quality care (Goldschmidt, 2012). In order for facilities to receive

incentive payments, they not only need to adopt EHRs, but also prove that the EHR is being used

in a meaningful way to improve care (Blumenthal and Tavenner, 2010). Meaningful Use (MU)


objectives were developed by The Centers for Medicare and Medicaid Services (CMS) along

with the Department of Health and Human Services (DHHS) with the intent that incentives can

be obtained if these specified objectives were met (or penalties if not met). There are many

requirements for hospitals to meet Stage 1 of MU. Hospitals must attest that their EHR has the

capability of electronically sending patient information surrounding stroke and venous

thromboembolism (VTE) care, and throughput in the Emergency Department (ED) (Abett, Bates,

and Kachalia, 2011). CMS has provided the definitions for the quality measure sets, Stroke,

VTE, and ED Throughput, including what patient information facilities will be required to

monitor and report (Quality Net, 2012). Hospitals are already required to report data

surrounding ED Throughput to CMS, but the other two measure sets have remained optional.

Spectrum Health Zeeland Community Hospital (SHZCH) is required to adopt an EHR

and, by January 2013, attest that the EHR has the capability to meet MU requirements. The

hospital has already addressed how data will be captured for the required ED Throughput

measure set, however, the Stroke and VTE measures sets have yet to be addressed. Without

clearly guiding caregivers in providing and recording evidence-based care, there is a potential to

lose significant incentive payment and, most importantly, the potential to see a decrease in

quality of care. According to Simpson (2011), Nursing Informatics Specialists (NIS) are essential

in helping hospitals meet MU requirements due to their combined knowledge of nursing,

computer and information science. The facility does not have an NIS to aide in the

understanding of required nursing and physician documentation for the quality measure sets, to

assess if the EHR to be adopted covers all aspects of the required documentation, and to provide

the executive team with a clear explanation of how or if the requirements will be met.


The purpose of this paper is to present a project proposal that addresses how MU

requirements related to stroke and VTE care will be met for SHZCH, what gaps in the

requirements are present, and what can be improved to close those gaps. An overview of the

setting where the project will be implemented will be reviewed as will the qualifications and

background of the selected preceptor. The goals and objectives including the theory and

research behind the project will be presented along with clear timelines of activities to

accomplish the objectives. Letters indicating full agency approval for the project will be

included, and an evaluation tool, developed to gain feedback about the project, will be explained.

Setting

The Scholarly Project will be completed for Spectrum Health Zeeland Community

Hospital (SHZCH). The hospital has been serving Zeeland and the surrounding communities for

over 80 years, and within the past six years has moved in to a brand new facility. The 57 bed

acute care hospital was built with all private rooms on the inpatient units as well as in the

Emergency Department. Units within the hospital include Emergency, Urgent Care,

Medical-Surgical Adult and Pediatrics, Bariatrics, Family Birth Center, Surgery, and ICU. The

Strategic Plan includes continued growth with the new Bariatrics program, Diabetes Center, and

will eventually focus on Women’s Health. The hospital employs over 500 staff members and

relies upon over 150 volunteers. The employees and volunteers have created a culture within the

hospital that truly encompasses the whole patient experience, not only the provision of safe,

quality care, but also the personalized experience that keeps patients choosing the hospital each

time care is needed.

Starting January 2011, SHZCH began integration into the Spectrum Health system with

full integration expected to be complete in two to three years. As part of the integration, the


Cerner Electronic Health Record (EHR) will be adopted by SHZCH by October 2012. The

Cerner EHR has been used by the Spectrum Health system for many years. Currently SHZCH

uses a mix of paper and electronic documentation processes using a very limited electronic

documentation system. The training of the basic knowledge for documentation in Cerner is

being planned for nurses by the Spectrum Health system’s Nursing Informatics department and

facilitated by SHZCH’s nursing directors, IT department, and nursing educator, however, there

has been little activity assessing how documentation surrounding Stroke and VTE quality

measures as part of the requirements to meet MU will be captured within the newly adopted

EHR. While the larger entities are addressing whether their current EHR build has the capability

to capture and send the required documentation to regulatory agencies, it is unknown whether the

build for SHZCH will adequately capture the information because of some differences in

processes at this smaller facility. There has been limited information provided to the executive

team of SHZCH, and therefore, they do not have a full understanding of the requirements for

meeting MU, nor whether the facility will be able to meet the requirements for the quality

measurement part of MU.

There is no specific department the project will be set in as activities for the project will

require contact with multidisciplinary groups from SHZCH and the Spectrum Health system

including Quality, IT, Education, Pharmacy, Medicine, Nursing, and Nursing Informatics. The

two measure sets require documentation from caregivers in multiple departments such as

emergency, medical-surgical, intensive care, and surgery. The EHR being adopted is split into

different modules for different areas of care. For example, the Emergency Department (ED) will

be using the Cerner product called FirstNet for ED related care, while the surgery department


will use SurgiNet for surgery related care. The setting for the project will span across multiple

departments.

Goal and Objectives

The goal of the Scholarly Project is to develop an executive level report and presentation

outlining how Meaningful Use (MU) requirements, related to the Stroke and VTE quality

measure sets, have been met for this facility. The report and presentation are the deliverables for

the project. The accomplishments of multiple objectives will enable the understanding of the

topic as well as aide in the creation of a succinct report and presentation to the executive team.

The Planning Guide in Appendix A contains a complete listing of goals, objectives, activities and

timelines for completion.

The first objective is to obtain the literature and information surrounding MU

requirements. The focus will stay on what the facility will need to attest to in relation to the

specific quality measures. Information surrounding documentation requirements for the Stroke

and VTE measure set compliance will also be gathered.

The second objective will include identifying the specific necessary documentation that is

required to for each measure within the measure sets. The Center for Medicare and Medicaid

Services (CMS) has a specification manual which outlines what data elements need to be

captured proving that care surrounding each measure has been provided (Quality Net, 2012).

The data elements required for each measure are highly specific and are listed in an alphabetical

data dictionary. CMS considers the information within the data dictionary to be their rules for

abstraction. Learning the necessary documentation is critical to the success of the project.

The third objective will be to learn all pertinent aspects of the Electronic Health Record

(EHR). The basics of documentation within the system will need to be understood before the


investigation of the how the EHR has been built to capture specifics surrounding the Stroke and

VTE measures can begin. Reigeluth’s Elaboration Theory (ET) includes a method of learning

based on how the basics of a topic are first mastered before more specifics about the topic can be

learned or new topics introduced (Cooper, 2009). Without basic knowledge of a topic, the

learner cannot understand in depth information surrounding the topic. Once meaning is gained

from the content, the learner becomes more confident and learning of the finer details can

continue. For this objective, the learning of how documentation surrounding the specific

measures is completed is considered the finer detail.

Performing a gap analysis for documentation needs that ensure measure set compliance

and the ability to attest to the MU requirements is the fourth objective. A gap analysis provides

the identification of differences, or gaps, between current state and what one wants the future

state to be (Rueckert, Krenzischek & Poe, 2011). Analyzing what has already been built into the

EHR, the current state, with the listing of documentation that is required; the future state should

reveal any gaps. The gap analysis is closely related to the next objective in which any identified

gaps related to missing data points within the EHR, either in general or in relation to the unique

needs of this smaller hospital, can be submitted to the Information Technology department for

improvement. Submitting improvements will be important because if the EHR is not built

according to what is needed, keeping in mind caregiver’s workflows, the technology will not be

useful for caregivers. Rogers (1995) created a theory called Diffusion of Innovations (DOI)

which examines the patterns of innovation adoption. Identifying the patterns of adoption in

various settings creates an opportunity to realize solutions to barriers and encourage a more

timely diffusion of the innovation. As DOI suggests, identifying and anticipating barriers

caregivers may encounter in an EHR not built to support what is required of them, will help


provide solutions and assist in the diffusion of the technology. EHRs have potential to cause

barriers to obtaining correct information for MU. The DOI theory is useful for this project as

identifying patterns of how the technology is currently built for and used by the main healthcare

system may reveal barriers and facilitate improvement applicable to this specific facility.

An objective related to communication with the hospital’s executive team is next. A

written report and presentation for the executive team will be prepared. The report and

presentation will contain information about how the facility will meet MU requirements related

to stroke and vte care through use of the EHR that is scheduled to be adopted. The executive

team will need to know the evidence behind use of an EHR to improve patient outcomes. They

also need to understand how the EHR will help caregivers prove care for patients included in

these measure sets has been given and that technology needs to be built to reliably automate

processes surrounding clinical practices (Hazlehurst, McBurnie, Mularski, Puro and Chauvie,

2009). The objective also includes the preparation of an evaluation tool so feedback can be

obtained.

The next objective is to give the presentation and written report to the executive team so

they can give feedback. The feedback will be reviewed with the preceptor. Any necessary

additional information the executive team requires can be obtained and given to them at a later

date.

Preceptor

The preceptor for the Scholarly Project is Julianne Carey, Director of Medical-Surgical,

Pediatrics, Bariatrics, Family Birth Center, Case and Utilization Management, and Medical

Social Work for Spectrum Health Zeeland Community Hospital (SHZCH) in Zeeland, Michigan.

Julianne started her nursing career as a Licensed Practical Nurse in a small, rural community


hospital east of Grand Rapids, Michigan. She is now a Bachelor prepared nurse with a Master’s

of Business Administration for Health Care Management, and has been employed by SHZCH

since 1997. Julianne reports directly to the Vice President of Clinical Services and has over 90

staff members that directly report to her including nurses, patient care technicians, unit

secretaries, case managers, medical social workers, and an administrative assistant. There are no

managers assigned to each department in this hospital, however, there are patient care managers

sharing shifts of daily hospital-wide coverage that also report to Julianne and the other nursing

director for the facility.

Along with Julianne’s directorship, she also is heavily involved in projects related to

technology adoption throughout the entire hospital. Prior to the integration into the Spectrum

Health system in 2011, the hospital was preparing to choose an Electronic Health Record (EHR).

Working with the Information Technology (IT) department, Julianne was an integral part in

research, site visit set-up, and analysis of each potential vendor. Simultaneously she helped her

own staff create an organized view of their everyday work enabling the staff to understand which

potential vendor’s product would be the most viable for their work and the organization in

general. Julianne’s expertise was also being used to guide choices of a vendor that would

support Computerized Physician Order Entry (CPOE).

Eventually, the hospital did not need to choose a vendor because of the decision to

integrate into a larger system that had an established EHR vendor. The integration work is

on-going and includes full adoption of the system’s EHR. Along with the healthcare system’s

project managers, IT and Nursing Informatics departments, Julianne is facilitating SHZCH’s

specific EHR build, mapping of her department’s current and future state workflow, nursing

staff’s EHR education, analysis of necessary nursing specific EHR hardware, and analysis of


needs related to Meaningful Use. Essentially she has been and for now will continue to fill these

roles that would be part of an Informatics Nurse Specialist’s (INS) practice, and therefore is an

ideal preceptor in assisting in the achievement of the goals and objectives for the proposed

Scholarly Project.

Activity Timelines

The Planning Guide in Appendix A includes a complete overview of all Timelines related

to accomplishing the activities for the project. Objective 1.1 includes multiple activities starting

with the search of various databases for research and information surrounding Meaningful Use

(MU) requirements, scheduled to be accomplished by June 5th. The same timeframe is identified

for searching The Center for Medicare and Medicaid Services’ (CMS) website, Quality Net, for

the documentation requirements surrounding the two measure sets, the compilation of the

literature and information source reference list, and information gathering from the healthcare

system’s lead of MU related to the Quality Measures. The amount of information to be reviewed

is extensive and therefore will take approximately three weeks to accomplish with a deadline of

June 5th.

Objective 1.2 includes just one activity. On preliminary review, the Stroke and Venous

Thromboembolism (VTE) measure sets include many measures and have specific, extensive

documentation requirements (Quality Net, 2012). Listing each measure and outlining the

required documentation for each measure is necessary for the future gap assessment and will

require some time to accomplish. The timeline for this activity includes a completion date of

June 15th.

Next, accomplishing Objective 1.3 will include learning the details of documentation

within the Cerner EHR. Learning these details will provide an overview of how Cerner has been


built to capture the measure sets’ required documentation. Attending Cerner classes that cover

nursing documentation, Computerized Physician Order Entry (CPOE), and the Lighthouse

product related to the quality metrics will need to be completed by June 29. Meeting with the

healthcare system’s Quality Department members who abstract the Stroke and VTE measure set

information from Cerner will allow further learning of the data points included in Cerner for

each measure. The meeting is scheduled to be completed by July 6. Cerner includes Power

Plans to guide care of patients with different diagnoses. A review of the current healthcare

system’s Power Plans related to Stroke and VTE will also enable learning of how the EHR has

been built to guide care of these types of patients and will be completed by July 6 as well. One

more activity for the objective will bring all information learned about Cerner together in one

outline. The data points surrounding Stroke and VTE care will be outlined as will the

information about where the data points are contained within the EHR. The outline will be

useful in the next objective and will be created by July 11.

Objective 1.4, performing the gap analysis, will be accomplished first by comparing the

list of measures and the required documentation for each with the outline of the data points

contained in Cerner created in the previous activity. The differences between what is required

and what Cerner currently contains will be identified, analyzed, and recorded, so the next activity

can facilitate filling those gaps (Rueckert, Krenzischek, & Poe, 2011). The gap analysis will be

completed no later than July 16.

According to VanAuken, Chrysler, Gricenko-Wells, and Simkin (2011), the gap analysis

results should be used to impact the organization’s needs. Submitting suggestions to fix any gaps

identified through the gap analysis will help meet Objective 1.5. The suggestions will be

submitted to the system’s IT department with the help of the SHZCH site-specific IT department.


The preceptor, as well as project managers for service lines that the suggestions may affect, will

be aware of the needed improvements and will facilitate the submission of the suggestions. The

improvements will be submitted no later than July 27.

A Power Point presentation and written report will be created to meet Objective 1.6 by

July 27. Both types of reports will be created so the executives not only have the information

verbally, but also in written format for later reference. The verbal presentation will also

encourage an open dialogue for questions and discussion. An evaluation tool will be created

during the same timeframe to ensure the information being presented is understood and has been

helpful. The presentation and written report will be given to the executive team at their weekly

meeting on July 30. At the end of the presentation, they will be asked to give feedback via the

evaluation tool.

The last activities will include reviewing the feedback with the preceptor and providing

any necessary additional information the executive team and preceptor feel were missing or still

requires clarification. Any updates can be provided in an addendum to the report and sent to the

executive team if needed. These activities will be completed by August 3.

Evaluation

An evaluation tool to determine whether all objectives for the Scholarly Project have

been adequately met is contained in Appendix C. I will provide feedback as will the preceptor

regarding whether the activities have enabled all objectives to be exceeded or met. The tool was

created to obtain qualitative feedback on the specific, measureable, attainable, relevant, and

timely (SMART) goals identified (Bovend’Eerdt, Botell, & Wade, 2009).

The first objective includes obtaining information related to Meaningful Use (MU)

requirements for attestation for the specific quality measures and documentation requirements

for both quality measure sets. A meeting with Spectrum Health’s lead for MU will also provide


an opportunity to learn. The accomplishment of the objective will be evident through the

provision of a literature and reference list.

The second objective includes identifying specific necessary documentation requirement

for each quality measure within each measure set. For instance, the Stroke measure set includes

eight different indicators each with varying points of documentation needed and the VTE

measure set includes six (Quality Net, 2012). Outlining the required documentation for each

indicator will allow for easier comparison in subsequent objectives. The outline provided will

show the accomplishment of the second objective.

Learning the electronic health record (EHR) system the facility will be adopting

including how the EHR has been built to capture documentation surrounding the measure sets is

the third objective. The first step in the objective includes learning the basics about

documentation and order entry within the system. The next step, learning specifics about how

the EHR has been built to capture specific documentation, cannot occur until the basics have

been learned. Charles Reigeluth’s Elaboration Theory (ET) supports this method of learning by

suggesting that a learner needs to master the basics of the tasks before the addition of further

learning material (Cooper, 2009). The final steps include meeting with Spectrum Health’s data

abstractors and reviewing the Power Plans related to the two measure sets to supplement the

information learned. The preceptor will be able to see whether the objective has been met

through review of the outline created to show all data points the EHR contains for documentation

related to measure set requirements.

The next two objectives include the performance of a gap analysis between current and

future needs related to the EHR and MU requirements. The preceptor understands that the

facility has unique needs within the EHR and the build will need to encompass these unique


needs as well as meet the requirements for MU. The objectives will be considered accomplished

after the comparison between the required documentation for each quality measure and the

outline of the EHR’s data points has been completed and the suggestions for improvement have

been submitted to the IT department. Both student and preceptor again will provide comments

or examples of accomplishment.

Next, the objectives related to preparation of report and presentation to the facility’s

executive team will be evaluated. Simpson (2009) suggests that nurse informaticians are highly

valuable to organizations in proving meaningful use of technology related to better patient

outcomes. The author feels that these nurses have knowledge of the MU requirements, data

points necessary for documentation, and knowledge of how the technology is used for

documentation. Therefore, an informative PowerPoint presentation and written report regarding

how the facility will meet MU requirement for the two quality measure sets will be created and

presented to the executive team. There will be opportunity for the executive team to provide

feedback through an evaluation tool. Once the presentation occurs, the feedback will be

reviewed with the preceptor. The objectives will be met if the preceptor feels the presentation

was succinct and informative as evidenced by feedback from the executive team.

Finally, the evaluation tool will ask for further identification of SMART goals the student

should address. The preceptor may have knowledge of other requirements for MU originally

thought to be unrelated to the quality measure sets, and therefore may recommend that the

student continue learning about other requirements that in the future could affect the work

already accomplished. There is one more area on the evaluation tool provided for any other

comments or recommendations related to the project.


Conclusion

While there is potential for technology to create safer care and better patient outcomes, barriers

such as incorrect usage, still exist. Through the use of the 2009 American Recovery and Reinvestment

Act (ARRA) and the Health Information Technology for Economic and Clinical Health Act (HITECH),

the government intends to incentivize facilities that show that their technology is used in a way that is

meaningful in improving patient care. This project proposal outlines how the Meaningful Use

requirements related to stroke and VTE care will be met for Spectrum Health Zeeland Community

Hospital. As there may be gaps in the requirements related to the electronic health record the facility is

adopting, the proposal includes the performance of a gap analysis giving the ability to identify and submit

improvement suggestions to the Information Technology department. Learning the requirement of MU as

well as the measure sets is essential during the project. The preceptor is very well qualified to evaluate

the work throughout the project as she has been integral in the adoption of new technology as well as the

implementation of technology related to nursing care. She will be able to evaluate the accomplishment of

the objectives including the presentation of findings from the project to the executive team.


References

Abbett, S. K., Bates, D. W., and Kachalia, A. (2011). The meaningful use regulations in

information technology: What do they mean for quality improvement in hospitals? The

Joint Commission Journal on Quality and Patient Safety, 37(7), 333-336.

Blumenthal, D. and Tavenner, M. (2010). The “Meaningful Use” regulation for electronic health

records. The New England Journal of Medicine, 363(6), 501-504.

doi:10.1056/NEJMp1006114

Bovend’Eerdt, T. J., Botell, R. E., and Wade, D. T. (2009). Writing SMART rehabilitation goals

and achieving goal attainment scaling: A practical guide. Clinical Rehabilitation, 23(4),

352-361. doi:10.1177/0269215508101741

Cooper, S. (2009). Charles M. Reigeluth: Elaboration theory. Theories of Learning in

Educational Psychology. Retrieved from http://www.lifecircles-

inc.com/Learningtheories/reigeluth.html

Goldschmidt, K. (2012). Finding meaning in meaningful use: Understanding the health

information technology for economic and clinical health act and its impact on nursing

practice. Journal of Pediatric Nursing, 27(1), 88-89. doi:10.1016/j.pedn.2011.10.002

Hazlenurst, B., McBurnie, M. A., Mularski, R., Puro, J., and Chauvie, S. (2009). Automating

quality measurement: A system for scalable, comprehensive, and routine care quality

assessment. AMIA 2009 Symposium Proceedings. Symposium conducted at the meeting

of AMIA, San Francisco, CA.

Huckvale, C., Car, J., Akiyama, M, Jaafar, S., Khoia, T., Khalid, A. B., Sheikh, A., and Majeed,

A. (2010). Information technology for patient safety. Quality and Safety in Healthcare,

19(Suppl 2), i25-i33. doi:10.1136/qshc.2009.038497


Quality Net (2012). Specification manual for the National Hospital Quality Measures. Retrieved

from http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic

%2FPage %2FQnetTier2&cid=1141662756099.

Rogers, E. M. (1995). Diffusion of innovations (4th ed.). New York, NY: The Free Press.

Rueckert, N. L., Krenzischek, D. A., & Poe, S. (2011). Conversion from paper to electronic

documentation: A data gap analysis process. Journal of PeriAnesthesia Nursing, 26(3),

195. doi:10.1016/j.jopan.2011.04.051

Shaw, G. (2012). Putting data in nurses’ hands. HealthLeaders. Retrieved from www.

healthleadersmedia.com

Simpson, R. L. (2011). Nurse informaticians critical to proving meaningful use. Nursing

Administration Quarterly, 35(1), 82-84. Doi:10.1097/NAQ.0b013e318203462a


APPENDIX A

NURS 710 Project Planning GuideProject: Meaningful Use requirements Executive level report and presentation.

Goals Objectives Activities TimelineGoal 1:

Develop an Executive level report and presentation outlining how Meaningful Use requirements, related to the Stroke and VTE quality measure sets, have been met for this facility by August 2012.

1.1

Obtain and review literature and information surrounding: Meaningful Use requirements for attestation related to the specific quality measures, and documentation requirements for Stroke and VTE measure set compliance.

1.2

Identify specific necessary

1.1 a

Search Cinahl, PubMed and other databases for research and information about Meaningful Use requirements.

1.1 b

Search Quality Net for the Center for Medicare and Medicaid Services’ Specification Manual related to measure set compliance requirements

1.1 c

Compile literature and other information sources’ reference list

1.1 d

Obtain information related to the quality metrics from Spectrum Health’s lead for Meaningful Use

1.2 a

List each measure within each measure

1.1 a

Complete by June 5, 2012

1.1 b


1.1 c


1.1 d


1.2 a



documentation requirements for each measure within each measure set

1.3

Learn the EHR system the facility will be adopting including how the EHR has been built to capture documentation surrounding the Stroke and VTE measure sets.

set and outline required documentation for each

1.3 a

Attend Cerner classes specific to nursing documentation

1.3 b

Attend Cerner CPOE classes

1.3 c

Review Cerner Lighthouse product related to quality metrics

1.3 d

Meet with Spectrum Health’s Quality department’s Stroke and VTE measure abstractors to learn specific areas of Cerner where data points related to each measure is documented

1.3 e

Review current Spectrum Health Power plans related to Stroke and VTE care

1.3 a


1.3 b


1.3 c


1.3 d


1.3 e

Complete by July 6, 2012


1.4

Perform a gap analysis for documentation needs that ensure measure set compliance and the ability to attest to the MU requirements.

1.5

As identified through the gap analysis, develop specific EHR data points that are still needed or need to be unique to this facility to meet requirements of MU and submit to facility’s Information Technology department.

1.3 f

Create outline of data points Cerner contains to capture documentation related to the measure sets and where in Cerner the data points are located

1.4 a

Compare previously created list of measures and required documentation with the outline of data points Cerner currently contains

1.4 b

Identify and outline the gaps between the two lists

1.5a

Submit suggestions of data points to capture necessary documentation

1.3 f


1.4 a


1.4 b


1.5 a

Submit by July 27, 2012


1.6

Prepare a report and presentation for the facility’s Executive team regarding how facility will meet MU requirements related to the two quality measure sets. Prepare an evaluation tool

1.7

Present report to Executive team and ask for feedback

1.8

Review feedback

1.6 a

Create a PowerPoint presentation as well as a written report for the executive team

1.6 b

Develop an evaluation tool

1.7 a

Present PowerPoint to executive team and administer evaluation tool

1.8 a

Review feedback with preceptor

1.8 b

Provide any necessary additional information to executive team and preceptor

1.6a


1.6 b


1.7a

July 30, 2012

1.8 a

August 3, 2012

1.8 b

August 3, 2012


APPENDIX B

Preceptor and Agency Agreements


APPENDIX C

Student-Preceptor Evaluation Tool

Student ____Jennifer Dilly______Preceptor ___Julianne Carey ___

For each objective, please provide comments or examples as to how objectives were exceeded, met, or not met.

Preceptor and Student Evaluation ToolObjective 1.1 Obtain and review literature and information surrounding Meaningful Use requirements for attestation related to the specific quality measures, and documentation requirements for Stroke and VTE measure set compliance.The student has researched Meaningful Use and the quality measure set compliance requirements from various databases, information sources, and through discussion with Spectrum Health’s lead for Meaningful Use. The research is evident through the provision of a literature and reference list.Preceptor Comments/Examples

Objective Exceeded Objective Met Objective Not Met

Student Comments/ExamplesObjective Exceeded Objective Met Objective Not Met

Objective 1.2 Identify specific necessary documentation requirements for each measure


within each measure setThe student has succinctly listed each measure within each measure sent and outlined the required documentation for each.Preceptor Comments/Examples



Objective 1.3 Learn the EHR system the facility will be adopting including how the EHR has been built to capture documentation surrounding the Stroke and VTE measure sets.Through attendance at various classes, the student has learned the basic documentation, computerized physician order entry, and quality metrics systems related to documentation of quality metrics for Meaningful Use. Additional meetings with Spectrum Health’s Quality department measure abstractors and review of applicable power plans has allowed the student to provide a succinct outline of data points related to documentation of the quality metrics for Meaningful Use.Preceptor Comments/Examples


Student Comments/Examples



Objective 1.4 Perform a gap analysis for documentation needs that ensure measure set compliance and the ability to attest to the MU requirements.The student has compared the required documentation for each quality measure with the outline of the EHR’s data points related to documentation of the quality metrics for Meaningful Use and has effectively identified and outlined the gaps between the two. Preceptor Comments/Examples



Objective 1.5 As identified through the gap analysis, develop specific EHR data points that are still needed or need to be unique to this facility to meet requirements of MU and submit to facility’s Information Technology department.As identified through the gap analysis, suggestions of data points necessary for capture of accurate documentation have been submitted.


Preceptor Comments/ExamplesObjective Exceeded Objective Met Objective Not Met


Objectives 1.6 and 1.7 Prepare a report and presentation for the facility’s Executive team regarding how facility will meet MU requirements related to the two quality measure sets. Prepare an evaluation tool. Present report to Executive team and ask for feedback. The student has created an informative PowerPoint presentation as well as a written report regarding how the facility will meet MU requirements for the two quality measure sets. The student has developed an evaluation tool to identify further information needed by the executive team. The student has effectively presented the Power Point to the executive team and obtained feedback.

Preceptor Comments/ExamplesObjective Exceeded Objective Met Objective Not Met



Objective 1.8 Review feedbackThe student has reviewed the executive team’s feedback with the preceptor and has provided them with any additional necessary information.Preceptor Comments/Examples



Please provide any further SMART (specific, measureable, attainable, relevant, timed) goals recommended:


Any additional comments/suggestions.

Student Signature __________________________________ Date __________________

Preceptor Signature ________________________________ Date __________________


APPENDIX D

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