Transcript 1QFY2013 CGPI Updatex

CGPI, FE, TBI ,HBPC
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Objectives

This presentation will provide an
overview of changes for the following
EPRP instruments and scoring
 CGPI
 TBI
 HBPC
 Frail Elderly

The other instruments are covered in a
separate presentation
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CGPI
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No changes to….
Validation module
 CHF module
 IHD module
 DM module

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CGPI Core Module
There are some changes to the series of
blood pressure questions in the Core
module
 q3 (seehtnpt) now reads:

 On (display BP1DT), was the patient seen by a
physician/APN/PA, pharmacist or RN case
manager?
 If the patient was seen by a pharmacist or RN
case manager only on the date the most recent
blood pressure was taken, there must be
documentation that the encounter was related to
management of the patient’s blood pressure in
order to answer yes
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Q4 prebps, prebpd
In question 4 you will enter the BP
recorded most immediately prior to the
BP you entered for q1
 The rules for an acceptable BP are the
same as in q1
 The date of the “prior BP” will be entered
in q5 and it must be prior to bp1dt and
less than or equal to one year before the
most recent blood pressure

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Changes to MOVE! Questions

Please note some changes to the D/D rules for
 Q21 (nowttx): Examples of health conditions that
may limit patient’s ability to participate in weight
management treatment
 Q23 (permnotx): Examples of permanent
contraindications to weight management

In both cases, the conditions must be
documented by a physician, APN or PA
(not a change) and are not limited to those
conditions listed in the rules
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Waist Circumference
Q23 (waistcir) now includes a timeframe
 During the past year, is the patient’s
waist circumference above 40 inches
(102cm) if male or above 35 inches (88
cm) if female?

 1. Yes (WC is above threshold)
 2. No (WC is at or below threshold)
 95. Not applicable
 99. No waist circumference documented
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CGPI Mental Health Module

Please review the list of acceptable
providers in the definition/decision rules of
questions
 33(deprisk)
 35 (depeval)
 40 (depmhevl)
 56 (ptsdrisk)
 58 (ptsdeval)
 63 (ptsdmhevl)
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Additions to Providers




Three new credentials have been added to the list
of acceptable providers that can document a
suicide ideation/behavior evaluation, document
that the patient needed further intervention or
document that a mental health evaluation was
needed
LMFT: Licensed Marriage and Family Therapist
LPMHC: Licensed Professional Mental Health
Counselor
RN: Registered Nurse
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CGPI Prevention Module



A reminder re: influenza immunization
“current immunization season” refers to the time
period September 1 2012 to March 31, 2013
If you don’t find flu immunization documented in
the medical record for the facility under review,
please look in remote data for this information
 This applies to abstraction of CGPI data as well as the
Global Measures data
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PI-New Question

Question 61 (nocrcscr) is new and is part
of the CRC screening questions

During the past five years, did the patient’s primary
care physician/APN/PA document that he/she does
not believe that this patient will experience a netbenefit from colorectal cancer screening because of
one or both of the following:
 Patient’s life expectancy is < 5 years because of
diagnoses or clinical factors (as specified in the progress
note)
 Patient could not tolerate the further work-up or treatment
(if the colorectal cancer screen was positive) because of
co-morbidities (as specified in the progress note)
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New Q61 (nocrcscr)

In order to answer yes to this question you must find
documentation by the patient’s primary care provider
(PCP) in a progress note that he/she does not believe
that this patient will experience a net benefit from CRC
screening
 No benefit is expected or
 Benefits are not expected to outweigh the harms
because of one or both of the bulleted points
○ Life expectancy less than 5 years
○ Patient could not tolerate the further work up or
treatment (if the screen was positive) because of
co-morbidities specified in the progress notes
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Q61
If no CRC screening was done in the
appropriate timeframe and nocrcscr is
answered “yes” it will serve as an
exclusion from p61h
 The previous question about a reason
that CRC screening was not clinically
indicated was removed

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Q62 Pap Test

Q62 (testpap) has been changed to ask for
the report of a Pap test performed within
the last 5 years
 Answer 1 or 3 as appropriate if a Pap test was
done within the last 5 years.
 This change is also reflected in answer option 7
which now reads
○ 7. All Pap test reports within the past five years
note sample was inadequate or that "no cervical
cells were present"

There are no other changes to the rules for
this question
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New Question 65

If the most recent Pap test was done
more than 3 years prior to the study
begin date you will get a new question

During the past five years, does the medical
record contain the report of a cervical human
papillomavirus (HPV) test performed for this
patient?
 1. HPV test performed by VHA
 3. HPV test performed by private sector provider
 99. No documentation HPV test performed
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HPV Test



Look in the lab package for the results of a human
papillomavirus (HPV) test which is usually
performed in conjunction with a Pap test
 Look at the cervical cytology reports first as the
HPV result may be found there
 Otherwise search under selected lab tests to
see if HPV or human papillomavirus is listed
Patient self-report is not acceptable
Results of HPV tests done at this VAMC must be
in the record
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HPV Test-Q65

If HPV test was done by another VAMC or private
sector provider, the abstractor must be certain the HPV
test was accomplished.
 The date must be documented closely enough to be
able to compute if the HPV test was accomplished
within the accepted time window
 Clinically relevant documentation must also include
findings, e.g., “positive”.

Historical information obtained by telephone by a
licensed member of the healthcare team and
entered in a CPRS progress note is acceptable, as
long as the outcome of the HPV test is known.
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Most Recent HPV and Result
You will enter the date of the most
recent cervical HPV test in the past 5
years in q66
 Enter the result of the most recent HPV
in q67

 1. Positive
 2. Negative
 99. Unable to determine

HPV testing is used in scoring which will
be discussed later in this presentation
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New Question 76 nocascrn

If testpap=99 and/or hpvtest=99,
and/or nomammo=2, you will get
question 76
 During the past five years, did the patient’s primary
care physician/APN/PA document that he/she does
not believe that this patient will experience a netbenefit from cancer screening (breast or cervical),
because of one or both of the following:
○ Patient’s life expectancy is < 5 years because of
diagnoses or clinical factors (as specified in the
progress note)
○ Patient could not tolerate the further work-up or
treatment (if the screen was positive) because of comorbidities (as specified in the progress note)
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nocascrn
Please review the definition/decision
rules for q76, which are like those for
q61, nocrcscr
 A “yes” answer to nocascrn will serve as
an exclusion for cervical and breast
measures which will be discussed later

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OP Medication Reconciliation
A new question has been added at the
beginning of the module
 The intent of the question is to
determine if medication(s) was
prescribed or modified during the most
recent NEXUS visit

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Q1 nexusrx
During the NEXUS clinic visit on
(computer to display NEXUSDT), did the
physician/APN/PA prescribe or modify
medications?
 If the patient was seen by a psychologist
or Clinical Nurse Specialist during the
most recent Nexus visit, answer “no”

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Q2 opmedrx
If you answer “yes” to question 1, you will
skip q2
 Q2 (which was the first question in
previous quarters) remains the same but
there are some changes to the d/d rules

 Instead of the long inclusion list in the rules,
there is only the exclusion list
 If medications were prescribed or modified by a
physician, APN or PA during the past year at an
OP visit to a clinic that is not on the exclusion
list, the answer is yes
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OP Med Recon
The remaining questions in this module
are essentially the same
 The timeframe in the questions will
reflect either the Nexus clinic visit date
(question 1) or the medrxdt (question 3)
depending on your answers

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CGPI Shared Module

There are changes to several questions in
the Shared module
 Statin medication questions have changed
 Blood pressure medication questions have
changed
The changes are reflected in new
measures dmg70 and ihd70 which will be
discussed later
 Please read the questions and rules
carefully as you review so that you are
aware of the changes

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Skip changes

There is a skip change in question 13
(ldlclvl2)
 If the most recent LDL is >=100 and was
done one year or more prior to the study
begin date, you will go to question 14
(previous LDL)

The skip that was prior to q55 in
previous quarters has been removed
resulting in a different path through the
statin medication questions
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Statin Medications

Note the timeframe change for Q55
 During the timeframe from (display NEXUSDT
– 100 days to NEXUSDT), does the record
document the patient was prescribed (or taking)
a statin medication?

Look back 100 days from the date of the
most recent NEXUS visit
 If the patient was prescribed (taking) a statin
during the specified timeframe, answer “1.”
 If the patient was not prescribed (not taking) a
statin during the specified timeframe, enter “2.”
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Statin Medications


If the patient was taking a statin medication in the
designated timeframe , enter which statin in q56
In q57 you will enter the highest daily dose of
statin medication the patient was prescribed
(taking) during the specified time period
 Look for any changes to the daily dose
during the time period
 Enter the highest daily dose
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Change Statin/Add Statin

The timeframe for the questions about changing
the statin dose or adding new statins (q58-62) has
changed to 90 days after the date of the most
recent NEXUS clinic visit and less than/equal
to the date of review
 If 90 days has not elapsed by the date of review and
no change has been made or no new statin was added
answer “no” to the relevant questions

For q62 you will enter the highest daily dose of
a new statin medication added during the 90
days (or up to the review date) after the NEXUS
visit date
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Blood Pressure Medications
There are several changes to blood
pressure medication questions
 Please review all highlighted sections of
the questions and definition/decision
rules

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Q64 vstbprx

Q64 has been changed to look back 100
days prior to the date of the most recent
blood pressure reading to see if the patient
was prescribed (taking) any antihypertensive medications listed in Table A

The applicable dates will be specified in
the question
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Highest Daily Dose


Q65 is the table for entering all anti-hypertensive
medications that the patient was prescribed
(taking) during the specified timeframe
You will enter each medication name and the
highest daily dose for each anti-htn medication the
patient was prescribed in that time period

If a medication dose was changed, select the entry
representing the highest daily dose prescribed
regardless of whether the dose was subsequently
decreased during the specified timeframe
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Moderate Dose
Anti-Hypertensives

The intent of q65 is to determine all antihypertensive medications the patient was
prescribed (taking) during the specified timeframe
and if moderate dose was prescribed.
 The drop down table contains entries for moderate dose
and greater, and less than moderate dose
 For example, the patient is prescribed lisinopril and the
highest daily dose during the time frame is 40 mg
○ Enter the name of the anti-hypertensive: Lisinopril
○ In the drop down box for dose in mg/day your choices will be
less than 20 mg OR
○ 20 mg or greater (this is the moderate dose)
○ In this example, choose 20 mg or greater
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Anti-hypertensive Table
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Anti-hypertensive Q65
If an anti-hypertensive medication was
discontinued during the timeframe and a
new anti-hypertensive medication was
added, enter name and daily dose for
both medications.
 If dose is not documented, do not select
the antihypertensive medication.

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Change /Add Anti-HTN Meds

The timeframe for the questions about changing
anti-htn meds or adding new anti-htn meds (q6668) has changed to 90 days after the date of the
most recent NEXUS clinic visit and less
than/equal to the date of review
 If 90 days has not elapsed by the date of review and
no change has been made or no new anti-htn meds
was added answer “no” to the relevant questions
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Change to Dose

Answer yes to q66 if a change was
made to the daily dose of an anti-HTN
med in the specified time period
 The medication dose was increased or
 The medication dose was decreased

If 90 days after the date the most recent
outpatient BP was documented has not
elapsed and there has not been a change to
an anti-hypertensive medication at the time of
review, answer “2.”
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New Medication Added
Answer “yes” to q67 if a new anti-htn
medication was added during the
specified timeframe
 If 90 days after the date the most recent
outpatient BP was documented has not
elapsed and an anti-hypertensive
medication was not newly prescribed at
the time of review, answer “2.”

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Table for Changes/Additions



Q68 is the table for entering each change or
addition of an anti-hypertensive medication that
occurred during the specified time period.
The intent is to determine all anti-hypertensive
medications that were changed or added during
the specified timeframe and if moderate dose was
prescribed.
The format of the table is the same as previously
described for q65
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Summary of changes for AntiHTN med questions



Look back period for meds is date of the most
recent OP BP to 100 days prior
Enter in the table in q65 the name of all anti-HTN
medications prescribed in specified timeframe
including meds that were discontinued and those
that were added
Determine the highest daily dose of each
medication that was prescribed in the time period
and enter that dose by selecting either
 XX mg or greater
 Less than XX mg
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Summary of changes for AntiHTN med questions



Timeframe to look for changes/additions to anti-htn
meds is 90 days after the date of the most recent
OP BP and less/equal to the date of review
Enter into the table in q68 the name of all antiHTN medications that were changed and those
that were added in specified timeframe
Determine the highest daily dose of each
medication changed/added in the time period and
enter that dose by selecting either
 XX mg or greater
 Less than XX mg
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CGPI Scoring / Exit Report
Changes

The influenza immunization measures
will not show on the exit report in 1Q
 p25h, p22h, p19
P3h (breast Screen age 50-69) has a
new exclusion: nocascrn=1
 P61h (colorectal screen) has a new
exclusion: nocrcscr=1

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CGPI Scoring / Exit Report
Changes

There are some new measures
 P41 Cervical screen age 21-64
○ HPV testing added to scoring
 P42 Cervical screen age 21-29
 P43 Cervical screen age 30-64
○ HPV testing added to scoring
 Nocascrn=1 will be an exclusion to the 3
cervical screen measures
 Ihd70 LDL<100 or moderate dose statin
(CVD)
 Dmg70 LDL<100 or moderate dose statin
(Diabetes)
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CGPI Scoring / Exit Report
Changes

New measures (continued)
 Ihd40: BP<140/90 or <150/65 or 3 moderate
dose anti-hypertensives (CVD)
 Dmg40: BP<140/90 or <150/65 or 3
moderate dose anti-hypertensives (DM
diagnosis)

Discontinued measures
 Ihd18hns; dmg25hs, scid6s: LDL<100 or
moderate dose statin
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CGPI Scoring / Exit Report
Changes
All changes will be detailed in the
1QFY13 CGPI Exit Report Guide
 Please review all changes, ask
questions as necessary and be
prepared to discuss them with your
facility

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Frail Elderly
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Dementia Diagnosis
The timeframe for q3 (demcisx) has
changed
 Look for documentation of the date of
onset and course of signs and
symptoms from 6 months prior to the
date of diagnosis to one month after

 The intent of the question is to determine if a
physician/APN/PA documented the approximate
date of onset or approximate length of time
cognitive impairment problem existed (e.g.,
days, weeks, etc.)…………………..
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Dementia History
Q4 has the same timeframe change
(added one month after diagnosis)
 Changes to answer options for q4

 4. Family history of dementia or other
cognitive impairment
 10. Behavioral Symptoms
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Dementia History

Additions to definition/decision rules
 Documentation of the presence or
absence of terms associated with items
1- 4 is acceptable (e.g., no history of head
trauma and history of depression, select
“1” and “2”).
 Behavioral symptoms – Examples include
but are not limited to agitation, aggression,
apathy, wandering, impulsivity, disinhibition,
sleep-wake cycle changes, inappropriate
sexual behavior.
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New Q5 (nodemhx)


During the time frame from (computer display
demedxdt – 6 months to demedxdt + 1 month), did
a physician/APN/PA document the patient’s history
and/or review of systems were unable to be
obtained?
Answer “yes” if there is physician/APN/PA
documentation during the specified timeframe that
information regarding the patient’s history and/or
review of systems could not be obtained from the
patient or caregiver
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Timeframe Change
One month after diagnosis was added to
the timeframe for questions 6-9
 Q9 also has changes to the answer
options

 Option 3 (serum folates) was removed
 Option 8 (BUN and creatinine) was removed
 New option 11 is serum creatinine
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FE Hospitalization Questions
There are no changes to the
Hospitalization questions of the FE
instrument for 1Q
 However we do wish to pass along a
few reminders based on findings from
4Q FY2013 Quality Control

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FE Reminders
Q25: During the ICU stay, did the
physician/APN/PA, registered nurse, or
social worker discuss preferences for
care with the patient?
 Count only documentation of a
discussion that took place during the
ICU stay; discussion before or after the
ICU stay does not count

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FE Reminders
Q36: By the end of hospital day 2, was a
plan for mobility documented?
 Remember that you are looking for a plan


A plan for mobility might be found in
 a nursing care plan
 nurses notes
 physician orders
 progress notes
 PT notes
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FE Reminders
Q48: Prior to discharge, were any post
discharge needs identified for the
patient?
 You must look in documentation prior to
discharge for identified needs
 It appears that post-discharge
documentation of needs has been
erroneously used in some cases

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FE Reminders
Q49: Prior to discharge, was the patient
evaluated for home health care
services?
 Do not confuse Tele-Health or Care
Coordination services with home health
care services

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FE Reminders

Does the medical record contain a copy of
written discharge instructions or
documentation of educational material
given to the patient or caregiver at
discharge, addressing
 Q55 Condition on discharge

Remember that condition on discharge
must be addressed in the discharge
instruction document that is given to the
patient/caregiver; documentation in a
different note does not count
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FE Scoring Changes-Pilot Report

FE18 (Diagnostic workup prior to
dementia diagnosis)
 Demhx10 (behavioral symptoms) added to
algorithm
 Serum folate and BUN deleted from the
algorithm

FE12, 19 and 19a were removed from
the Pilot Exit Report
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FE Scoring Changes-Pilot Report

New Measures
 FE181: History prior to dementia diagnosis
 FE 182: Physical exam prior to dementia
diagnosis
 FE183: Laboratory testing prior to dementia
diagnosis

The Pilot Exit Report Guide will provide
details of the scoring
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TBI
There are no changes to the TBI
instrument
 No changes to TBI scoring

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HBPC
No changes to the HBPC instrument
 No changes to HBPC scoring

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Reminders
Please remember that it is your
responsibility to review remote data
(care provided at other VA facilities)
when applicable
 It is always best to get an immediate
start on each pull list and avoid a last
minute rush to complete work

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Prepare for 1QFY2013
Also review the PPT presentation for
changes to inpatient instruments
 Complete the 1QFY2013 Learning
Assessment
 The good work you do for EPRP is
greatly appreciated!

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