NCQA PCMH Data Reporting and Nextgen Needs

NCQA PCMH Data Reporting and NextGen Needs December 18, 2012 Measure Description Report 1.A.1 Show availability of same-day appts At least 5 day report showing same-day or 3rd throughout each practice next available. Must show that this is monitored by the practice 1.A.2 Show timely clinical advice by phone At least 5 day report, may be system generated or report summarizing actual response time compared against practice standard. Must show that this is monitored by the practice 1.A.3 Show timely advice by secure, At least 1 week report summarizing actual interactive electronic system response time against practice standard Patient Portal 1.A.4 Show documentation of clinical advice A recent 1 month measurement period, given by phone and/or electronic denominator=number of pts receiving clinical message advice, numerator=number of pts with clinical advice documented in the medical record. Must provide percentage 1.B.3 Show timely clinical advice when At least 5 day report summarizing actual practice is closed response times compared against practice standard. Must show that this is monitored by the practice 1.B.4 Show timely advice by secure, At least 5 day report, may be system generated interactive electronic system when or report summarizing actual response time practice is closed compared against practice standard. Must show that this is monitored by the practice

1.B.5 Show documentation of clinical advice A recent 1 month measurement period, given by phone and/or electronic denominator=number of pts receiving after-hours message when practice is closed clinical advice, numerator=number of pts with after-hours clinical advice documented in the medical record. Must provide percentage 1.C.1* Show percentage of pts who got Reporting period=recent 12 month period Core electronic copy of health information Denominator=Number of pts who request MU within 3 business days of request electronic copy of their electronic health info Numerator=Number of pts in denominator who receive requested info within 3 business days 1.C.2** Show percentage of pts given electronic Reporting period=recent 12 month period Menu access to requested health information Denominator=Number of pts seen by practice MU within 4 business days of it being Numerator=Number of pts in denominator who available to practice have electronic access to their health info within 4 business days of being updated in the EHR Patient Portal 1.C.3* Show percentage of office visits for Reporting period=recent 12 month period Core which electronically-generated clinical Denominator=Number of office visits

NCQA PCMH Data Reporting and NextGen Needs December 18, 2012 MU summaries were provided to pts within Numerator=Number of office visits in 3 business days (may be by secure denominator for which pts were provided a electronic message or as printed copy clinical summary of their visit within 3 business from practice’s electronic system days Measure Description Report 1.C.4-6 Two-way communication Patient Portal-screenshot showing electronic Patient request for appt or Rx refills capability Patient request for referrals or test results 1.D.3 Show total proportions of pt encounters At least 1 week of data, showing total proportion that occurred with PCP or PCP’s team of pt encounters with their PCP. Must show that this is monitored by the practice Report Store- Jean (able to retrieve) 1.E Medical Home Responsibilities PCMH checkbox in EPM 1.F.1 Show assessment of racial and ethnic Report diversity of practice population 1.F.2 Show assessment of language needs of Report practice population 2.A Factors 1-12 may be reported together, must be reported as percentages based on 12 months of data in the EHR. Denominator=Number of pts seen by practice at least once during 12 month reporting period (except for factor 11 which only includes those who meet age parameters) Numerator-Number of pts in denominator for whom the specified data are entered for each data element 2.A.1* Date of birth Core MU 2.A.2* Gender Core MU 2.A.3* Race May align race and ethnicity categories with Core those used by the Office of Management and MU Budget. Those who prefer not to provide 2.A.4* Ethnicity race/ethnicity may be counted in numerator if Core practice documents declination to provide info MU 2.A.5* Preferred Language Blank field may not be counted as English Core MU 2.A.6 Telephone numbers Blank field may not be counted as none 2.A.7 E-mail address Blank field may not be counted as none 2.A.8 Dates of previous clinical visits Visits must be distinguished from electronic and phone advice

NCQA PCMH Data Reporting and NextGen Needs December 18, 2012 2.A.9 Legal guardian/health care proxy 2.A.10 Primary caregiver Blank field may not be counted as none 2.A.11 Presence of advance directives NA for pediatric patients 2.A.12 Health insurance information Blank field may not be counted as none

NCQA PCMH Data Reporting and NextGen Needs December 18, 2012 Measure Description Report 2.B.1 Current & active problem list for Must be reported as >80% percentages based on 12 2.B.2 Allergies & associated reactions months of data in EHR for >80% Denominator-Number of pts 2.B.3 B/P readings for >3yrs for >50% seen by practice at least once 2.B.4 Height for >2yrs >50% during 12 month reporting 2.B.5 Weight for >2yrs >50% period 2.B.8 Tobacco Use for >13yrs >50% (except for factors 3, 4, 5 and 8 2.B.9 Rx’s with date of updates for which include those meeting age >80% parameters) Numerator=Number of pts in denominator for whom specific data are entered for each element 2.D Factors 1 & 2 blend 2 Menu Meaningful Use requirements Reports must demonstrate practices identified and provided outreach to pts in need of services Reports or lists of pts needing services generated within past 12 months 2.D.1 At least 3 different preventive care Used lists to remind pts services 2.D.2 At least 3 different chronic care services Used lists to remind pts 2.D.3 Pts not recently seen by practice Used lists to remind pts 2.D.4 Specific medications Used lists to remind pts 3.A.1-3 Three Important conditions Protocols 3.B.2 Show number & percentage of Denominator=Total number of total population identified as pts in practice high risk or complex Numerator=Pts identified as high risk or complex Show numbers and percentages 3.C Document that care teams perform the following for at least 75% of the pts identified in Elements A and B 3.C.1 Conduct pre-visit planning Denominator=Total number of 3.C.2 Develops care plan & treatment pts with important conditions goals with family AND review & identified in Elements A and B update each relevant visit Numerator=Number of pts 3.C.3 Pt/family given written care plan identified in the denominator for 3.C.4 Assess & address barriers when whom each item is entered in goals not met the EHR 3.C.5 Pt/family given clinical summary Care Plan Template at each relevant visit Pre-Planning Checkbox in EHR 3.C.6 Identify pts/families who might (1/16/13 added, needs to be in- benefit from additional care serviced at sites- completed at

NCQA PCMH Data Reporting and NextGen Needs December 18, 2012 management support CSD ed sessions) 3.C.7 Follow up canceled or no- showed relevant appts

NCQA PCMH Data Reporting and NextGen Needs December 18, 2012 Measure Description Report 3.D Show medication management for Denominator=Total number of pts pts identified in 3.A and 3.B with important conditions 3.D.1** Reconcile meds for >50% of care identified in Elements A and B who transitions had at least 1 relevant visit in 3.D.2 Reconcile meds for >80% of care recent 3 month period transitions Numerator=Pts from denominator 3.D.3 Info on new Rx to >80% for whom items are entered into 3.D.4 Assess Rx understanding for>50% the EHR with date of assessment 3.D.5 Assess response to med & barriers to adherence>50% with assessment date Checkbox on Med. Reconciliation 3.D.6 OTC’s, herbals, supplements template for OTCs documented>50% with update (Jan ’13- added and in-serviced in date Jan.)

**Menu Meaningful Use 3.E.1* Show 40% eligible Rx’s transmitted *Core MU, 12 month reporting period Core electronically Denominator=Eligible Rx’s written by practice MU Numerator=Eligible Rx’s generated AND transmitted electronically 3.E.2 Show 75% eligible Rx’s generated 12 month reporting period electronically Denominator= Eligible Rx’s written by practice Numerator=Eligible Rx’s generated electronically 3.E.3 Show >30% med orders entered into Denominator=Pts in practice with at least 1 medication EHR for pts with >1 med on med list Numerator=Pts in denominator with at least 1 med entered directly into med record using EHR 4.A.1 Show ed resources given or refers >50% Denominator=Number of pts identified in 3.A and 3.B to ed resources to assist in self- who had at least one relevant visit in recent 3 month management support period 4.A.2** Show EHR used to identify pt-specific ed Numerator=Pts in denominator for whom each of the Menu resources and provides them to >10% item is entered in medical record MU 4.A.3 Show self-management goal setting, Built in logic for patient specific education based on care planning & way to monitor self- diagnosis care. If meeting Tx goals, must document pt instructed to maintain current self-care plan 4.A.4 Show documentation of assessment of self-management abilities for >50%

NCQA PCMH Data Reporting and NextGen Needs December 18, 2012 4.A.5 Show provision of self-management tools to record self-care results for >50% 4.A.6 Counsels >50% of pts to adopt health behaviors 4.B.2 Show referral tracking to community Reporting period of 1 month, show community resources referral tracking for all practice pts with community referral

Measure Description Report 5.A.9** Show >40% of all clinical lab test results Reporting period of 12 months Menu incorporated into structured fields in Denominator=Lab tests ordered during reporting MU medical records period with results expressed in a positive or negative affirmation or number Numerator=Lab tests in denominator which are incorporated as structured data 5.B.1 Show specialist referrals include reason Reporting period at least 1 week for & urgency, relevant clinical info, Generate report from EHR demonstrating data general purpose of referral collected in tracking referrals 5.B.2 Show referral tracking includes date of initiation & time for receiving report 5.B.3 Show follow up to obtain reports not received 5.B.6 Demonstrates capability for electronic Vendor test report demonstrating capability exchange of information between clinicians 5.B.7** Show provision of electronic 12 month reporting period Menu MU summary of care to another Denominator=Number of referrals provider for >50% of referrals during report period Numerator=Referrals in denominator where summary of care record was provided 5.C.8** Show provision of electronic 12 month reporting period Menu MU summary-of-care to another care Denominator=Number of facility for >50% of transitions of transitions to another care setting care during reporting period Nominator=Number in denominator where summary-of- care was provided 6.A.1 Show measurement and receipt of Report on cervical CA screening, 2 data on at least 3 preventive care yr old immunization rates, measures colorectal CA screening 6.A.2 Show measurement and receipt of Report on DM’s A1C <9%, HTN’s data on at least three chronic or B/P<140/90mm/hg, CAD with

NCQA PCMH Data Reporting and NextGen Needs December 18, 2012 acute care clinical measures lipid-lowering Rx 6.A.3 Show measurement and receipt of Report on Imaging Use For Low data on at least two utilization Back Pain and number of specialist measures referrals 6.A.4 Show reports from 6.A.1-3 Stratify reports for 6.A.1-3 by stratified for vulnerable pts<200% poverty and race and populations ethnicity 6.B.1 Show conduction of survey evaluating at least 3 of the following: Access, Communication, Coordination, Whole-person care/self- management support 6.B.2 Show CAHPS survey tool results 6.B.3 Show requests for feedback of vulnerable groups 6.B.4 Show requests for qualitative feedback Pink-Must Pass Yellow-Critical Factor