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Possible "seen by" bug for CQR/MU

Bugs, Known Issues, Open Cases

Last Post by Anonymous 1 second ago

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ronmoses

(@ronmoses)

Posts: 158

Estimable Member

Topic starter

I'm still working with GE on this, but I feel pretty confident that there's a bug in the "seen by" calculations for CQR/MU. For those who don't know, "seen by" is a criteria used for determining the denominator for the majority of Meaningful Use measures. According to my research, this number is being over-counted in the following scenario:

Patient visits a provider other than their primary. Could be Urgent Care, a specialist, whatever. That provider opens a document of type "Office Note" and signs it. Patient's primary care provider gets a notification of the visit, reviews the note, then contributes an additional signature to the document. That visit is now counted as "seen by" in the primary's MU denominators.

This only happens with Office Visits, as far as I can tell. It doesn't even extend to other document types in the Patient Encounter (MU) document view. Reading the definition of "seen by" given by GE in the Achieving Meaningful Use with Centricity Practice Solution document, it does not seem like these should be counted. It doesn't meet any of the given criteria as far as I can see. And yet if you drill down into the CQR data for the primary and the patient, you'll see an entry for "seen by" relating to that document. It's clearly happening - I'm just waiting for GE to tell me that it's supposed to be happening (in which case they have about a dozen follow-up questions to answer) or that it's a bug (and a huge one at that).

Just curious if anyone else has seen this? I'll be happy to provide more detail on how to identify instances of this if anyone's interested.

Posted : June 11, 2015 8:27 am

tstevens0426

(@tstevens0426)

Posts: 65

Trusted Member

I am interested. I wonder if this is what is happening with us where one provider is getting counted for a measure when they are not the primary and they are the surgeon or one of our other specialists and they didn't see the patient for an OV. Thank you.

Posted : June 11, 2015 9:18 am

ronmoses

(@ronmoses)

Posts: 158

Estimable Member

Topic starter

I'm not sure this would be related to that issue, as this is sort of the reverse. You're talking about a specialist who actually saw the patient. In our case, it's a primary who did not see the patient, but only added a signature to the document.

The surgeon, assuming they are an EP, would have that patient counted if the document type is part of the "Patient Encounter (MU)" document view. It isn't limited to OVs. If you can identify the document for which you believe the patient is being counted, you can look it up in Adminstration > Charts > Chart > Document Views. Set the dropdown to "<Global List>", scroll down to select "Patient Encounter (MU)", and click "Change or Copy". The Document Types list will show all the types that count towards Meaningful Use. If the doc type the surgeon used is checked, that explains why the patient is being counted in their denominator.

Then there's E&M Service Orders, which can also contribute to the denominator, and also SNOMED codes. But I haven't dug as far into either of those two pieces as I have into the document side of things.

Posted : June 11, 2015 9:29 am

dduschel

(@dduschel)

Posts: 207

Reputable Member

Yes we see this. Talking with GE I was told that was expected behavior. Our MDs have to oversign the NPs so they get attributed to their patients as well. I want to retire before they figure that out.
Thanks
Dawn

Posted : June 11, 2015 9:44 am

bruins1986

(@bruins1986)

Posts: 233

Reputable Member

Hi Ron,

We were told this was not a bug originally but have recently raised the concern again and received a more tempered response - hopefully it will be addressed. An EP will get "credit" for any office visit were they performed the following CONT_ACTION types in the DOCCONTB table:

0,3,6,7,8,9

These correspond to:

0 - Create

1 - Edit

3 - Append

6- Initial Signature

7- Final Signature

8- Additional Signature

9- Commit Clinical List Changes

Hopefully this will be changed, it is the same reason NP visits are counting under the EP when in the past it was an option to include if you wanted (by adding in the numbers). CMS states this is optional (to include NP or not). Including another providers document is definitely wrong and should be a bug however. We raised this concern originally in November or December but have not had any progress since - a major reason we are exploring crystal reports as an option to attestation.

We determined this by reverse engineering the denominator lists for multiple providers. I am worried GE has doubled down on this as their calculation method based on the following excerpt from the newest MU guide:

"Any user who signs for a document or its appends is counted as the Eligible Provider (EP)
regarding "seen by" concept. Only add document types to the Patient Encounter (MU) view that you use to document patient encounters"

From the "seen by" definition note.

Thanks

Mike

Posted : June 11, 2015 9:53 am

kdevin

(@kdevin)

Posts: 75

Estimable Member

We are also experiencing this. I do believe that it is a flaw in their logic. We are a large multi-specialty clinic and for the last 8 + years our providers co-sign on notes when a specialist has seen the patient - to indicate that they have reviewed and acknowledge the specialists assessment and plan for the patient. Now our PCP's get dinged for some of the measures because the specialist failed to provide patient education (for instance).

Curious if others are having a problem with GE's interpretation of the Timely access measure (Patient Portal). Their logic is that the portal access must be present prior to, during or within 4 days of the first "seen by" encounter during the reporting period. So if the patient comes in multiple times in the reporting period and the provider convinces them on the 2nd or 3rd visit to sign up for the portal- they fall in the unmet category.

Posted : June 11, 2015 10:45 am

ronmoses

(@ronmoses)

Posts: 158

Estimable Member

Topic starter

I just had a long phone call with two top-level brains at GE, and it was also confirmed that this is expected behavior, with the exception of a small bug that's currently being addressed. Without getting into a lot of detail right now (because I was supposed to go home two hours ago), this could represent some major workflow changes for our providers. They're not going to like this at all.

Posted : June 11, 2015 11:25 am

bruins1986

(@bruins1986)

Posts: 233

Reputable Member

kdevin - what you are experiencing is true. Unfortunately the CMS rule seems (from my reading) to confirm GE's interpretation - "within 4 business days of the information being available to the provider" ( http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/Stage2_EPCore_7_PatientElectronicAccess.pdf) means to me within 4 business days of the first visit of the reporting period (the first time information is available to the EP during the reporting period).

CMS is still taking feedback questions/concerns in regards to their proposed stage 2 changes - unfortunately we've already exhausted our questions on other measures but I would definitely suggest asking for clarification by CMS on if it has to be the first visit of the period.

My concern major concern with this and GE (as we are multi practice/multi specialty as well) is if they count the first visit as the first visit in the organization (EMR) or by location/provider. If it is the organization a patient who sees a specialist not participating in MU and does not receive a PIN but later sees a provider who is and they do generate a PIN are they already "out" because of that first visit... we have not yet been able to confirm or rule this out.

Ron - that is concerning but echoes what we have heard as well - which can be boiled down to "too bad". We have many standing questions about the CQR calculations and what GE may do to help, I will be sure to post if they respond and with what they say.

Thanks

Mike

Posted : June 12, 2015 2:47 am

ronmoses

(@ronmoses)

Posts: 158

Estimable Member

Topic starter

For whatever it's worth (very little IMO), apparently there was a great deal of debate within GE as to whether co-signs should count towards "seen by". I'm not surprised to find many users think the wrong side won that argument. But I have to be somewhat sympathetic - there's just no way they could possibly accommodate every possible workflow.

So as I understand it, we have three options:

Live with it.
Stop co-signing any documents you don't want to be responsible for.
Remove all the current document types from the "Patient Encounter (MU)" doc view, creating a new "Do Not Use" doctype and adding that to the view instead. Then set up the patient encounter form to insert an order that uses SNOMED code SCT-308335008, which will be signed by the provider that actually saw the patient.

Option 3 sounds the least painful.

Posted : June 12, 2015 3:31 am

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