VTE/Stroke
Meaningful Use Clinical Rules
2014 Guidelines
Strategic – Proactive
Review and Setup
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Review of UMLS (2014 requirements)
◦ And formerly HITSP
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Clinical Quality Measures review
Value Set review
Evaluate site specific criteria to implement 5
clinical decision support “interventions”
◦ MU Stage II requirement
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End with clear understanding and mini-toolset to
initiate/finalize site specific conversations
regarding these MU Stage II requirements
Note: the Client Server 5.66 platform was utilized for the basis of this presentation
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WILL NOT review global Meaningful Use items
WILL NOT interpret ARRA/CMS code
WILL NOT provide actual Plug-N-Play rules
for production
◦ Due to the nature and complexity of these rules,
future Webinars will cover actual build and rollout
Advanced Rules - VTE-Stroke Deployment
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Healthcare Information Technology Standards
Panel (HITSP)
Unified Medical Language System (UMLS)
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RxNorm
LOINC
SNOMED
ICD-9
ICD-10
“..The value sets contain all the data elements previously found in
HITSP TN906 v1.1 specifications. Upon reviewing the value sets, it
will be clear that the reliance on codified data has increased
exponentially. National and international standards are becoming a
necessity for exchanging data for interoperability and for quality
reporting. “
MEDITECH's Best Practice documents contain
workflow methods which have been vetted
through numerous clinical and customer
representatives. The corresponding SQL
reports have been created with precise
alignment to the workflow methods found
within the Best Practice documents in
conformance with the 2014 specifications. 1

“Use clinical decision support to improve
performance on high-priority health
conditions”
[For Stage II]…Implement 5 clinical decision support
interventions related to 4 or more clinical quality
measures, if applicable, at a relevant point in patient
care for the entire EHR reporting period.
CMS eMeasure ID
NQF #
Measure Title
Measure Description
104
0435
Stroke-2 Ischemic stroke –
Discharged on anti-thrombotic
therapy.
71
0436
Stroke-3 Ischemic stroke –
Anticoagulation Therapy for Atrial
Fibrillation/Flutter
91
0437
Stroke-4 Ischemic stroke –
Thrombolytic Therapy
72
0438
Stroke-5 Ischemic stroke –
Antithrombotic therapy by end of
hospital day two
105
0439
Stroke-6 Ischemic stroke –
Discharged on Statin Medication
Ischemic stroke patients prescribed
antithrombotic therapy at hospital
discharge.
Ischemic stroke patients with atrial
fibrillation/flutter who are prescribed
anticoagulation therapy at hospital
discharge.
Acute ischemic stroke patients who
arrive at this hospital within 2 hours
(120 minutes) of time last known
well and for whom IV t-PA was
initiated at this hospital within 3
hours (180 minutes) of time last
known well.
Ischemic stroke patients
administered antithrombotic therapy
by the end of hospital day two.
Ischemic stroke patients with LDL
greater than or equal to 100 mg/dL,
or LDL not measured, or, who were
on a lipid- lowering medication prior
to hospital arrival are prescribed
statin medication at hospital
discharge.
CMS eMeasure ID
NQF #
107
0440
102
0441
Measure Title
Measure Description
Ischemic or hemorrhagic stroke
patients or their caregivers who
were given educational materials
during the hospital stay addressing
all of the following: activation of
Stroke-8 Ischemic or hemorrhagic
emergency medical system, need
stroke – Stroke education
for follow-up after discharge,
medications prescribed at
discharge, risk factors for stroke,
and warning signs and symptoms of
stroke.
Ischemic or hemorrhagic stroke
Stroke-10 Ischemic or hemorrhagic
patients who were assessed for
stroke – Assessed for Rehabilitation
rehabilitation services.

Stroke-2 (ischemic)
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Stroke-3 (ischemic)
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Stroke-4 (ischemic)
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Stroke-5 (ischemic)
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Stroke-6 (ischemic)
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Stroke-8 (ischemic/hemorrhagic)
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Stroke-10 (ischemic/hemorrhagic)
◦ Discharged on Antithrombotic Therapy
◦ Discharged on Anticoagulation Therapy
◦ Atrial Fibrillation/Flutter
◦ Thrombotic Therapy – 2 hr arrival/3 hr IV t-PA
◦ Antithrombotic therapy by end of hospital day 2
◦ Discharged on Statin Medication (LDL>100 or prior use)
◦ Stroke Education
◦ Assessed for Rehabilitation
You are not required to use all items in a value set
in your system. You can choose to use only those
which most closely match your workflow and
patient needs. However, any items you do include
must be mapped to the standard nomenclature.
For example, when creating a group response for
contraindications for ordering a medication, all of
the reasons in the value set do not have to be
included. The elements in the group response
must all come from the value set and must all be
mapped to the nomenclature specified in the value
set.1
1
Data Capture for Stroke/VTE Measures, MEDITECH CS Best Practice Documentation
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Medication, Discharge: Anticoagulant Therapy
using Anticoagulant Therapy RxNorm Value Set
(2.16.840.1.113883.3.117.1.7.1.200)
Medication, Order: Thrombolytic (t-PA) Therapy
using Thrombolytic (t-PA) Therapy RxNorm Value
Set (2.16.840.1.113883.3.117.1.7.1.226)
Medication, Administered: Antithrombotic
Therapy using Antithrombotic Therapy RxNorm
Value Set (2.16.840.1.113883.3.117.1.7.1.201).
Medication, Discharge: Statin using Statin
RxNorm Value Set
(2.16.840.1.113883.3.117.1.7.1.225).

The following value sets are used for stroke
diagnosis:
◦ Diagnosis, Active: Hemorrhagic Stroke using
Hemorrhagic Stroke Grouping value set
(2.16.840.1.113883.3.117.1.7.1.212).
◦ Diagnosis, Active: Ischemic Stroke using Ischemic
Stroke Grouping value set
(2.16.840.1.113883.3.117.1.7.1.247).

Value set for the LDL test:
◦ Laboratory Test, Result: LDL-c using LDL-c LOINC
Value Set (2.16.840.1.113883.3.117.1.7.1.215).

Value sets for Palliative Care:
◦ Intervention, Order: Palliative Care using Palliative
Care SNOMED CT Value
Set:(2.16.840.1.113883.3.526.2.1076).
◦ Intervention, Performed: Palliative Care using
Palliative Care SNOMED CT Value Set:
(2.16.840.1.113883.3.526.2.1076).
CMS eMeasure ID
NQF #
108
0371
190
0372
Measure Title
Measure Description
This measure assesses the number
of patients who received VTE
prophylaxis or have documentation
Venous Thromboembolism (VTE)-1 why no VTE prophylaxis was given
VTE prophylaxis
the day of or the day after hospital
admission or surgery end date for
surgeries that start the day of or the
day after hospital admission.
This measure assesses the number
of patients who received VTE
prophylaxis or have documentation
why no VTE prophylaxis was given
VTE-2 Intensive Care Unit (ICU)
the day of or the day after the initial
VTE prophylaxis
admission (or transfer) to the ICU or
surgery end date for surgeries that
start the day of or the day after ICU
admission (or transfer).
CMS eMeasure ID
NQF #
73
0373
109
0374
Measure Title
Measure Description
This measure assesses the number
of patients diagnosed with
confirmed VTE who received an
overlap of parenteral (intravenous
[IV] or subcutaneous [subcu])
anticoagulation and warfarin
therapy. For patients who received
less than five days of overlap
therapy, they must be discharged
VTE-3 VTE Patients with
on both medications or have a
Anticoagulation Overlap Therapy
reason for discontinuation of overlap
therapy. Overlap therapy must be
administered for at least five days
with an international normalized
ratio (INR) greater than or equal to 2
prior to discontinuation of the
parenteral anticoagulation therapy,
discharged on both medications or
have a reason for discontinuation of
overlap therapy.
This measure assesses the number
of patients diagnosed with
VTE-4 VTE Patients Receiving
confirmed VTE who received
Unfractionated Heparin (UFH) with intravenous (IV) UFH therapy
Dosages/Platelet Count Monitoring dosages AND had their platelet
by Protocol (or Nomogram)
counts monitored using defined
parameters such as a nomogram or
protocol.
CMS eMeasure ID
NQF #
Measure Title
110
0375
VTE-5 VTE discharge instructions
114
0376
VTE-6 Incidence of potentially
preventable VTE
Measure Description
This measure assesses the number
of patients diagnosed with
confirmed VTE that are discharged
to home, home care, court/law
enforcement or home on hospice
care on warfarin with written
discharge instructions that address
all four criteria: compliance issues,
dietary advice, follow-up monitoring,
and information about the potential
for adverse drug
reactions/interactions.
This measure assesses the number
of patients diagnosed with
confirmed VTE during
hospitalization (not present at
admission) who did not receive VTE
prophylaxis between hospital
admission and the day before the
VTE diagnostic testing order date.
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VTE-1
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VTE-2
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VTE-3 (confirmed VTE)
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VTE-4 (confirmed VTE)
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VTE-5 (confirmed VTE)
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VTE-6 (confirmed VTE during stay)
◦ VTE Prophylaxis
◦ ICU VTE Prophylaxis
◦ Anticoagulation Overlap Therapy (IV/SQ and Warfarin)
for 5 days (INR>2)
◦ Unfractionated Heparin AND monitored platelets
◦ Discharge Instructions
◦ Not present at admission and did not receive VTE
prophylaxis
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Value sets for Pharmacologic Prophylaxis:
◦ Medication, Administered: Direct Thrombin Inhibitor using Direct Thrombin Inhibitor
RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.205).
◦ Medication, Administered: Injectable Factor Xa Inhibitor using Injectable Factor Xa
Inhibitor RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.211).
◦ Medication, Administered: Low Molecular Weight Heparin using Low Molecular Weight
Heparin RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.219).
◦ Medication, Administered: Oral Factor Xa Inhibitor using Oral Factor Xa Inhibitor
RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.134).
◦ Medication, Administered: Unfractionated Heparin using Unfractionated Heparin
RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.218).
◦ Medication, Order: Parenteral Anticoagulant using Parenteral Anticoagulant
RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.266).
◦ Medication, Administered: Warfarin using Warfarin RxNorm Value Set
(2.16.840.1.113883.3.117.1.7.1.232).
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If unfractionated heparin is used, the following value sets regarding
Route of Administration will be checked:
◦ Attribute: Route: Subcutaneous route using Subcutaneous route SNOMED-CT Value
Set (2.16.840.1.113883.3.117.1.7.1.223).
◦ Attribute: Route: Intravenous route using Intravenous route SNOMED-CT Value Set
(2.16.840.1.113883.3.117.1.7.1.222).
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Value Set for INR Procedure:
◦ Laboratory Test, Result: INR using INR LOINC Value
Set (2.16.840.1.113883.3.117.1.7.1.213).
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Value sets for Palliative Care:
◦ Intervention, Order: Palliative Care using Palliative
Care SNOMED CT Value
Set:(2.16.840.1.113883.3.526.2.1076).
◦ Intervention, Performed: Palliative Care using
Palliative Care SNOMED CT Value Set:
(2.16.840.1.113883.3.526.2.1076).
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The VTE measures use the following value set from VSAC to
determine VTE population:
◦ Diagnosis, Active: Venous Thromboembolism using Venous
Thromboembolism Grouping Value Set
(2.16.840.1.113883.3.117.1.7.1.279).
◦ Diagnosis, Active: Atrial Fibrillation/Flutter using Atrial Fibrillation/Flutter
Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.202).
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The following value sets are used to exclude patients:
◦ Diagnosis, Active: Obstetrics VTE using Obstetrics VTE Grouping Value Set
(2.16.840.1.113883.3.117.1.7.1.264).
◦ Diagnosis, Active: Obstetrics using Obstetrics Grouping Value Set
(2.16.840.1.113883.3.117.1.7.1.263).
◦ Diagnosis, Active: Hemorrhagic Stroke using Hemorrhagic Stroke Grouping
Value Set (2.16.840.1.113883.3.117.1.7.1.212).
◦ Diagnosis, Active: Ischemic Stroke using Ischemic Stroke Grouping Value
Set (2.16.840.1.113883.3.117.1.7.1.247).
◦ Diagnosis, Active: Mental Disorders using Mental Disorders Grouping
Value Set (2.16.840.1.113883.3.117.1.7.1.262).
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Value set for Diagnostic Test:
◦ Diagnostic Study, Result: VTE Diagnostic Test using
VTE Diagnostic Test Grouping Value Set
(2.16.840.1.113883.3.117.1.7.1.276).
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Value Set for confirmed VTE:
◦ Attribute: Result: VTE Confirmed using VTE
Confirmed SNOMED CT Value Set
(2.16.840.1.113883.3.117.1.7.1.407).
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Patient age
Resuscitation status
Problem List
Provider – yes/no
Diagnosis vs. Problem List
Drug Type (AHFS Classification)
◦ Inpatient “active” medication orders
◦ Ambulatory “active” medication orders
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“Confirmed VTE”
◦ Procedure Status vs. SNOMED CT Value Set content
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Monitored LAB values
Challenges
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Site Specific Workflow
◦ Patient Assessments (VTE/Stroke)
 Performed when and by whom
◦ Dictionary Specific Build
 Standardization for multi-site facilities
◦ Provider/Physician Expectations
 Required at Order Entry?
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Admission criteria
◦ Inclusion/Exclusion (e.g. ICU direct admit)
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Medication Identification – PHA Drug Formulary
Drug Type
Customer Defined Parameter
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Medication Identification – PHA Drug Formulary
◦ Value Set differences (HITSP/VSAC)
 Stroke has Warfarin, VTE DOES NOT!
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Medication Identification – RXM Drug
Drug Type
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“Provider” Identification
◦ MIS User Dictionary
 Profile
 This User is Provider
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“Diagnosis” Identification
◦ Typically done post discharge in ABS by Coders
◦ Problem List
◦ New Keywords for rules (Magic and CS)
 [f pt prob current]
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“Confirmed” VTE
◦ What determines a “complete”/”reported” exam
and/or procedure
 At what point does the Status change
◦ Role based, multi-collaborative process
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Where Rules are attached
Remember  …relevant point in patient care…
◦ POM Enabled
◦ OE/OM Categories
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MED
LAB
MIC
RAD
◦ PHA/POM Enabled Rules
 “Global” in PHA Customer Defined Parameters
◦ Less Popular - Underutilized
 PHA Refill Rules
 LAB Verify Rules
Examples
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Description
◦ Ischemic stroke patients prescribed antithrombotic
therapy at hospital discharge.
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Initial Patient Population
◦ Patients admitted to the hospital for inpatient acute
care with a principal diagnosis code for ischemic or
hemorrhagic stroke with hospital stays <= 120
days during the measurement period for patients
age 18 and older at the time of hospital admission.
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NQF 0435 Measure captures patients who are
prescribed antithrombotic therapy at discharge.
◦ In the 2011 specifications, HITSP provided a SNOMED
code to use to document the provider’s intention to
send the patient home on a specific discharge
medication. This SNOMED was INT and was used in a
query on an order in POM. This allowed an alternate
workflow to documenting discharge medications in
discharge. However, this SNOMED code is not
included in the 2014 specifications. Therefore, no
alternate workflow is possible. All discharge
medications must be documented through the
Discharge routine.
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Rule Logic must contain
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Ischemic Stroke “diagnosis”
NOT Comfort Care (resuscitation order)
Patient age > 18
Length of Stay < 120 days
Antithrombotic therapy at discharge
 Home Meds/Discharged Meds
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Description

Initial Patient Population
◦ This measure assesses the number of patients diagnosed with
confirmed VTE who received overlaps of parenteral (intravenous
[IV] or subcutaneous [subcu]) anticoagulation and warfarin
therapies. Patients who received fewer than five days of overlap
therapy should be discharged on both medications or have a
reason for discontinuation of overlap therapy. Overlap therapy
should be administered for at least five days with an international
normalized ratio (INR) greater than or equal to two prior to
discontinuation of the parenteral anticoagulation therapy,
discharged on both medications, or have a reason for
discontinuation of overlap therapy.
◦ Patients with a diagnosis code for venous thromboembolism
(VTE), a patient age greater than or equal to 18 years, and a
length of stay less than or equal to 120 days.

NQF 0373 Measure captures patients who are
prescribed antithrombotic therapy at discharge.
◦ In the 2011 specifications, HITSP provided a SNOMED
code to use to document the provider’s intention to send
the patient home on a specified discharge medication.
This SNOMED was INT 40 and was used in a query on an
order in POM. This allowed an alternate workflow to
documenting discharge medications in discharge.
However, this SNOMED code is not included in the 2014
specifications. Therefore, no alternate workflow is
possible. All discharge medications must be documented
through the Discharge routine.
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Rule Logic must contain
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Confirmed VTE
NOT Comfort Care (resuscitation order)
Patient age > 18
Length of Stay < 120 days
5+ days with INR > 2
Inpatient IV Anticoagulant Therapy
Inpatient PO Anticoagulant Therapy
Ambulatory PO Anticoagulant Therapy
Stroke 2
VTE 3
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Potential MEDITECH Functionality Additions
◦ Rule Evaluation
 At “Open Chart” via EMR
◦ Discharge Functionality
 Multi-collaborative
 DON’T GET US STARTED!
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Stage 3 Recommendations
◦ “…Implement 15 clinical decision support interventions
or guidance related to five or more clinical quality
measures that are presented at a relevant point in
patient care for the entire EHR reporting period…”2
2 SGRP113:
Clinical Decision Support, Draft Recommendations Meaningful Use Stage 3, Paul Tang et al
Kevin McConnell, PharmD, PHD.
Co-founder and Executive VP of Service Delivery
Kevin has 24 years of relevant professional experience including over 13
years’ experience as a MEDITECH consultant, project manager, and
application specialist in healthcare system implementation and
assessments. Specializing in the implementation and support of MEDITECH’s
Advanced Clinical Applications and related applications and interfaces. Areas
of expertise include Meaningful Use assessments and planning, pre and post
implementation assessments, developing implementation and training plans,
revenue cycle, coordinating process and departmental workflow
enhancement/redesign, facilitating/managing application implementation
teams, training end-users and change management. Past positions include,
but are not limited too, Director of Pharmacy, Clinical Pharmacist, Staff
Pharmacist, Instructor at a College of Pharmacy, and owner of a
retail/community pharmacy.
Kevin is a frequent Presenter at the Annual MUSE International Conferences
including topics such as Writing Clinical Rule and PHA/NPR for Dummies.