17 MU Core Measures EPs must meet ALL

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1 EHR INCENTIVE PROGRAM Falcon EHR Meaningful Use Stage 2 Checklist 2014 See the CMS EHR Incentive Programs website for more detailed information on MU measures. MU #1 MEASURE CPOE (COMPUTERIZED PHYSICIAN DER ENTRY) F MEDICATIONS, LABATY, AND RADIOLOGY DERS 60% / 30% / 30% or Excluded More than 60 percent of medication, 30 percent of laboratory, and 30 percent of radiology orders created by the EP during the EHR reporting period are recorded using CPOE. EXCLUSION: Any EP who writes fewer than 100 medication, radiology, or laboratory orders during the EHR reporting period. Note: Exclusions apply to each part of the measure individually. If an EP excludes from one part, they must still meet or exclude from the other parts. 17 MU Core Measures EPs must meet ALL FALCON ACTION a. CPOE Meds (60%): Use either of the below calculations for attesting to CPOE a. Med orders (alt or regular): The alternate calculation is: 1a.CPOE for Medication Orders (Alt) (60%): Use Falcon to create new prescriptions. Each new prescription whether called in, printed or sent electronically is counted in this measure as the denominator and the numerator. This is the Alternative Calculation that is offered. The regular calculation is: 1a. CPOE for Medication Orders (60%) # of unique patients seen in the reporting period that have at least 1 prescription on their med list # of unique patients seen in the reporting period that have a med prescription entered into Falcon in the medication list (meds that are prescriptions count. The method of transmission does not matter call-in, print or eprescribe are ALL orders that count) Providers can use either calculation for attestation. Only one is required. Both will always be 100% as long as the provider prescribes meds in Falcon. b. CPOE for Radiology Orders (30%): Diagnostic order using a CPT code indicative of radiology order and save. ( ). Main Menu > Order Entry > Diagnostic Order Diagnostic order using a CPT code indicative of radiology order and save. ( ). Main Menu > Order Entry > Diagnostic Order This will always be a 100% measure as the denominator and numerator are the same thing in Falcon. c. CPOE for Laboratory Orders (30%): Printable lab orders created and saved under Main Menu > Order Entry. Printable lab orders created and saved under Main Menu > Order Entry This will always be a 100% measure as the denominators and numerators are the same thing in Falcon.

2 MU #2 E-PRESCRIBING (ERX) 50% or Excluded More than 50 percent of all permissible prescriptions, or all prescriptions, written by the EP are queried for a drug formulary and transmitted electronically using CEHRT. EXCLUSION: Any EP who: (1) Writes fewer than 100 permissible prescriptions during the EHR reporting period. (2) Does not have a pharmacy within their organization and there are no pharmacies that accept electronic prescriptions within 10 miles of the EP's practice location at the start of his/her EHR reporting period. MU #3 RECD DEMOGRAPHICS 80% or Excluded More than 80 percent of all unique patients seen by the EP have demographics recorded as structured data. If a Core Measure requires an 80% threshold, then at least 80% of patient s records must be maintained in the CERHT in order for the provider to achieve that threshold. Use Falcon-SureScripts certified prescription module to send prescriptions electronically to pharmacies. Main Menu > Patient Manager > Medications > Add > New Prescription echarting > Meds > +Medication > New Prescription Click Send to Pharmacy or Send to Provider (who will then approve and send to pharmacy) when prescribing medications. Note: Using Print Prescription or Call-in Prescription counts against this measure. DENOMINAT = All prescriptions entered in Falcon as New Prescription type (using the button New Prescriptions ) (Refills from the Msg Ctr DO NOT COUNT) NUMERAT = All prescriptions entered in Falcon as New Prescription type AND sent to the pharmacy electronically ( Send to Pharmacy ) In Patient Manager > Demographics record all of the following demographics for office patients and dialysis patients: a. Preferred language b. Gender c. Race d. Ethnicity e. Date of Birth DENOMINAT = Number of unique patient Office and Dialysis encounters during the reporting period NUMERAT = Number of patients in the denominator that have all above demographics entered. MU #4 RECD VITALS MU #4 RECD VITALS SIGNS BP MU #4 RECD VITALS HEIGHT AND WEIGHT 80% or Excluded Any one of the three options for Vital Signs measure can be use to attest for MU # 4. In the encounter record vital signs: Height Weight Blood Pressure Calculate and display body mass index (BMI) (Falcon auto calculates BMI when Height and weight is entered) 80% of both dialysis patients and office patients must have vitals recorded in the reporting period. Record Vital Signs BP This is an alternative measure for MU#4 which can be v /30/2014 Page 2 of 13

3 More than 80 percent of all unique patients seen by the EP have blood pressure (for patients age 3 and over only) and/or height and weight (for all ages) recorded as structured data. EXCLUSION: Any EP who: (1) Sees no patients 3 years or older is excluded from recording blood pressure. (2) Believes that all 3 vital signs of height/length, weight, and blood pressure have no relevance to their scope of practice is excluded from recording them. (3) Believes that height/length and weight are relevant to their scope of practice, but blood pressure is not, is excluded from recording blood pressure. (4) Believes that blood pressure is relevant to their scope of practice, but height/length and weight are not, is excluded from recording height/length and weight. If a Core Measure requires an 80% threshold, then at least 80% of patient s records must be maintained in the CERHT in order for the provider to achieve that threshold. used for attestation. Patients that have had as visit in the reporting period and have had BP recorded will be added to this measure. Record Vital Signs Height and Weight This is an alternative measure for MU#4 which can be used for attestation. Patients that have had as visit in the reporting period and have had Height and Weight recorded will be added to this measure. DENOMINAT = Number of unique patient Office and Dialysis encounters during the reporting period NUMERAT = Number of patients in the denominator that have vitals recorded at least once in reporting period. MU #5 RECD SMOKING STATUS 80% or Excluded More than 80 percent of all unique patients 13 years old or older seen by the EP have smoking status recorded as structured data. EXCLUSION: Any EP that neither sees nor admits any patients 13 years old or older. If a Core Measure requires an 80% threshold, then at least 80% of patient s records must be maintained in the CERHT in order for the provider to achieve that threshold. Record smoking status in encounter note for patients 13 and older This field is usually found in Past Medical History, Social History section or Health History section. DENOMINAT = Number of unique patient Office and Dialysis encounters during the reporting period NUMERAT = Number of patients in the denominator that have smoking status recorded at least once in reporting period. v /30/2014 Page 3 of 13

4 MU #6 CLINICAL DECISION SUPPT YES or NO or Excluded Measure 1: Implement five (5) clinical decision support interventions related to four or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period. Absent four clinical quality measures related to an EP s scope of practice or patient population, the clinical decision support interventions must be related to highpriority health conditions. Measure 2: The EP has enabled and implemented the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period. Measure 1: Enter at least five CDS (Clinical Decision Support) rules in Main Menu > Clinical Decision Support relevant to Clinical quality measure PRI to starting the reporting period. Print a screen shot of the programs you set up showing the creation date. To see the creation date, click on the program. Measure 2: In Main Menu > Practice Manager > Drug Interaction Settings Enable these two for the entire reporting period: Drug-Drug Interactions (Drug-Drug) Prior Adverse Reactions (Drug-Allergy) EXCLUSION: For the second measure, any EP who writes fewer than 100 medication orders during the EHR reporting period. MU #7 PATIENT ELECTRONIC ACCESS 50% & 5% or Excluded Measure 1: More than 50 percent of all unique patients seen by the EP during the EHR reporting period are provided timely (available to the patient within 4 business days after the information is available to the EP) online access to their health information. Measure 2: More than 5 percent of all unique patients seen by the EP during the EHR reporting period (or their authorized representatives) view, download, or transmit to a third party their health information. EXCLUSION: Any EP who: (1) Neither orders nor creates any of the information listed for inclusion as part of both measures, except for "Patient name" and "Provider's name and office contact information, may exclude both measures. (2) Conducts 50 % or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 3Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude only the second measure. 7a.(50%)- Measure 1: Generate a patient portal PIN for patients seen in the reporting period. When this is done in Falcon sends the patient s CCDA to the portal and the data is populated in the portal for this patient. How to generate a PIN for a patient: During the checkout workflow, click checkbox to generate PIN and create welcome letter. Give letter to the patient. If the patient has an in demographics, they will also get an with the link to the portal website. Patient Manager > Patient Demographics > Click button to Generate Patient Portal PIN DENOMINAT = Number of unique patient Office and Dialysis encounters during the reporting period NUMERAT = Number of patients in the denominator that have had a PIN generated within 4 days of their encounter or prior to their encounter. 7b. (5%) Measure 2: v /30/2014 Page 4 of 13

5 Patients need to login to the portal with the Falcon generated PIN. Portal URL: DENOMINAT = Number of unique patient Office and Dialysis encounters during the reporting period NUMERAT = Number of patients in the denominator that have registered and logged into the Health Companion portal. MU #8 CLINICAL SUMMARIES 50% or Excluded Clinical summaries provided to patients or patientauthorized representatives within one business day for more than 50 percent of office visits. EXCLUSION: Any EP who has no office visits during the EHR reporting period. Print or a Clinical Summary for at least 50% of patients within one day of their office visit. ONLY for patients that have an OFFICE VISIT. Dialysis patient encounters do not count towards the denominator of this measure Several ways to do this: Check-out: Click box to print Clinical Summary AND click Print Documents button. Patient Manager > Clinical Summary, Send to Patient button, Print as PDF or echarting > Visit Shortcuts > Send to Patient (DOES NOT APPLY TO DIALYSIS ENCOUNTERS) MU #9 PROTECT ELECTRONIC HEALTH INFMATION YES or NO Conduct or review a security risk analysis in accordance with the requirements under 45 CFR (a) (1), including addressing the encryption/security of data stored in CEHRT in accordance with requirements under 45 CFR (a)(2)(iv) and 45 CFR (d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the provider's risk management process for EPs. DENOMINAT = Number of unique patient Office encounters during the reporting period NUMERAT = Number of patients in the denominator that have had a Clinical Summary generated within 1 day of encounter. Evaluate Falcon security based on requirements specified in measure. See the Small Practice Security Guide under Meaningful Use Folder in Falcon Online Guide and Meaningful Use Risk Assessment. Print out the Falcon Security Risk Assessment document, review, sign and date and keep for your records. v /30/2014 Page 5 of 13

6 MU #10 CLINICAL LAB TEST RESULTS 55% or Excluded More than 55 percent of all clinical lab tests results ordered by the EP during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in Certified EHR Technology as structured data EXCLUSION: Any EP who orders no lab tests where results are either in a positive/negative affirmation or numeric format during the EHR reporting period. DENOMINAT: Number of lab tests ordered during the EHR reporting period by the EP whose results are expressed in a positive or negative affirmation or as a number. NUMERAT: Number of lab test results which are expressed in a positive or negative affirmation or as a numeric result which are incorporated in CEHRT as structured data. If you have an interfaced lab or DVA Labs then the clinical lab test results are flowing into Falcon and being stored as structured data in Patient Manager > Results Inquiry. If you do not have a lab interface then you can manually enter lab results into Patient Manager > Results Inquiry For the denominator, providers must enter lab orders into Falcon.. DENOMINAT = The number of Lab orders entered into Falcon that have results in Falcon in structured date, with a collection date within the reporting period. NUMERAT = The number of Lab results in Falcon in structured data that have a date within the reporting period MU #11 PATIENT LISTS YES or NO Create one report in Main Menu > Quick List with any filter using one or more problems (diagnosis). Print the report, and date it and keep for your records. Generate at least one report listing patients of the EP with a specific condition MU #12 PREVENTIVE CARE 10% of patients with 2 or more office visits with the EP within the past 24 months before the beginning of the EHR reporting period or Excluded More than 10 percent of all unique patients who have had 2 or more office visits with the EP within the 24 months before the beginning of the EHR reporting period were sent a reminder, per patient preference when available. EXCLUSION: Any EP who has had no office visits in the 24 months before the EHR reporting period. Quick Lists > Patient Reminders Choose MU Stage 2 Reminders Choose Q3 or Q4 (quarter 3 or quarter 4) Note: MUST use the patients preferred method or that patient is removed from the numerator Run the report and check off at least 10% of the patients in the report results to Dispatch Reminders to. DENOMINAT = Patients with 2 or more office visits in the past 2 years with this provider NUMERAT = Patient in the denominator that were dispatched reminders by their preference (set in demographics screen) v /30/2014 Page 6 of 13

7 MU #13 PATIENT-SPECIFIC EDUCATION RESOURCES 10% or Excluded Patient-specific education resources identified by Certified EHR Technology are provided to patients for more than 10 percent of all unique patients with office visits seen by the EP during the EHR reporting period. EXCLUSION: Any EP who has no office visits during the EHR reporting period. MU #14 MEDICATION RECONCILIATION 50% or Excluded The EP who performs medication reconciliation for more than 50 percent of transitions of care in which the patient is transitioned into the care of the EP. EXCLUSION: Any EP who was not the recipient of any transitions of care during the EHR reporting period. The measure of this objective does not dictate what information must be included in medication reconciliation. Information included in the process of medication reconciliation is appropriately determined by the provider and patient. Include Education Materials in the encounter note in the Plan section. Office Visits count in the denominator of this measures. Click on Visit Shortcuts and Education Materials to choose which documents to include in the encounter for the patient or click on the Online Educational tab to print online materials for the patient. DENOMINAT = Number of unique patient Office encounters during the reporting period NUMERAT = Number of patients in the denominator that have educational material added to their encounter anytime in the past Do reconciliation by using checkboxes in the encounter or do this electronically using Direct. Checkbox method: There are three checkboxes in your encounter (usually in Meds/Allergies section or Dialysis MU section). You can check these to meet the measure: DENOMINAT: Patient has been transitioned into my care. This checkbox is the denominator and if checked, will count this patient as one that was transitioned into your care and should have their meds reconciled. NUMERAT: Medication reconciliation has been performed This checkbox is the numerator and if checked, will count this patient as having had meds reconciled Needed in addition for the NUMERAT for Followup patients: Summary of Care received This needs to be checked ONLY for FOLLOWUP patients. You should have received a Summary of Care document from another provider which includes a medication list used to reconcile meds. Any format is acceptable as long as the provider believes it contains an accurate listing of meds and can be used to reconcile the patient s medications. Electronic method: If you want to do this reconciliation electronically, DO NOT check any boxes and do the reconciliation from the Message Center > Direct Message received. Electronically reconcile meds when a CCDA is v /30/2014 Page 7 of 13

8 received via Direct in Message Center. Click on CCDA message received in Direct Messages in Message Center and then click +Clinical Info button. Move meds from the CCDA into Falcon as needed. MU #15 (a & b) TRANSITION OF CARE SUMMARY 50% / 10% / Yes/No or Excluded EPs must satisfy both of the following measures in order to meet the objective: Measure 1: (50%) (a. Transition of Care Summary Record) The EP who transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 50 percent of transitions of care and referrals. Measure 2: (10%) (b. Transition of Care Electronic Summary of Care Record (Direct)) The EP who transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 10 percent of such transitions and referrals either (a) electronically transmitted using CEHRT to a recipient or (b) where the recipient receives the summary of care record via exchange facilitated by an organization that is a NwHIN Exchange participant or in a manner that is consistent with the governance mechanism ONC establishes for the NwHIN. Measure 3: (Yes/No) An EP must satisfy one of the following criteria: Conducts one or more successful electronic exchanges of a summary of care document, as part of which is counted in "measure 2" (for EPs the measure at 495.6(j)(14)(ii)(B) with a recipient who has EHR technology that was developed designed by a different EHR technology developer than the sender's EHR technology certified to 45 CFR (b)(2). Conducts one or more successful tests with the CMS designated test EHR during the EHR reporting period. EXCLUSION: Any EP who transfers a patient to another setting or refers a patient to another provider less than 100 times during the EHR reporting period is excluded from all three measures. Measure 1: There are two checkboxes in your encounter (usually in Plan section). One checkbox is used to add the patient to the denominator and the other is to add the patient to the numerator of the measure. Patient is being referred to another physician for a consultation or is patient being transitioned to a new provider (and leaving your care). DENOMINAT = If this box is checked, the patient is added to the denominator. This indicates the physician should be communicating to another provider about this patient. The patient s Clinical Summary document should be sent directly from Falcon to the other provider. Do this using DIRECT messaging. Patient s Clinical Summary will be provided to the consulting or new physician NUMERAT = If this box is checked, the patient is added to the numerator indicating that the physician sent or will send the CCDA/Clinical Summary to the Physician he/she is referring the patient TO the new physician the patient is transitioning TO. Measure 2: Send the Clinical Summary (TOC/CCDA) document via DIRECT messaging from: Visit Shortcuts > Send to Provider Or Patient Manager > Clinical Summary > Send to Provider Measure 3: Send a Clinical Summary document via Direct messaging to provider with a different EHR. (Same as Measure 2 above) v /30/2014 Page 8 of 13

9 MU #16 IMMUNIZATION REGISTRIES YES or NO or Excluded Successful ongoing submission of electronic immunization data from CEHRT to an immunization registry or immunization information system for the entire EHR reporting period. EXCLUSION: Any EP that meets one or more of the following criteria may be excluded from this objective: (1) the EP does not administer any of the immunizations to any of the populations for which data is collected by their jurisdiction's immunization registry or immunization information system during the EHR reporting period; (2) the EP operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required for CEHRT at the start of their EHR reporting period; (3) the EP operates in a jurisdiction where no immunization registry or immunization information system provides information timely on capability to receive immunization data; or (4) the EP operates in a jurisdiction for which no immunization registry or immunization information system that is capable of accepting the specific standards required by CEHRT at the start of their EHR reporting period can enroll additional EPs. Use the Vaccines link on left side of echarting to document administered vaccinations. Or enter historical vaccines under Vaccine History. (must have a date). For historical data - Place of Service is your practice and indicates where the patient was seen and not where vaccine administered. NOTE: All Immunization sections in encounters have been disabled. ALL VACCINES MUST BE ENTERED ON LEFT SIDE OF echarting through the VACCINES link. Records are sent directly, electronically to your state registry. Please contact your Falcon Account Manager to verify the state has received the vaccine records you have entered. MU#17 SECURE ELECTRONIC MESSAGING 5% or Excluded A secure message was sent using the electronic messaging function of CEHRT by more than 5 percent of unique patients (or their authorized representatives) seen by the EP during the EHR reporting period. EXCLUSION: Any EP who has no office visits during the EHR reporting period, or any EP who conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 3Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period. Patients that login to the patient portal with their PIN automatically trigger a secure message to be sent to their Physician in Falcon. The patient can send a message from portal to their Falcon physician. They can do this in the Patient Portal under Messages > Compose NOTE: Providers receive the message in Falcon Message Center but cannot reply. This indicates the patient has completed registration for the portal. DENOMINAT = Number of unique patient Office and Dialysis encounters during the reporting period NUMERAT = Number of patients in the denominator that have registered and logged into the Health Companion portal for the first time (and SM was automatically sent) sent a secure message from the portal to the physician v /30/2014 Page 9 of 13

10 Menu Set Measures Must meet 3 (Falcon offers these 3 only) Exclusions are allowed however please speak to your Falcon Account Manager if you feel you MUST use an exclusion for one of these 3. MENU SET (MS) MEASURES FALCON ACTION MS #2 ELECTRONIC NOTES 30% Enter at least one electronic progress note created, edited and signed by an EP for more than 30 percent of unique patients with at least one office visit during the EHR reporting period. The text of the electronic note must be text searchable and may contain drawings and other content. MS #3 IMAGING RESULTS 10% or Excluded More than 10 percent of all tests whose result is one or more images ordered by the EP during the EHR reporting period are accessible through CEHRT. EXCLUSION: Any EP who orders less than 100 tests whose result is an image during the EHR reporting period; or any EP who has no access to electronic imaging results at the start of the EHR reporting period. Complete encounter notes for all office patient visits visits in Falcon Physician. Once the encounter is finalized it will count for the denominator and numerator of this measure. Notes that are in progress, amended, and not finalized, do not go in the numerator Deactivated encounters are removed from the denominator and numerator. DENOMINAT = Number of Office encounters during the reporting period NUMERAT = Number of Office encounters during the reporting period that are in a finalized or finalized/amended status Upload image documents to Patient Manager > Documents and choose the category; Cardiac, EKG, Imaging, Pathology, Radiology or Xray and Create radiology orders in Falcon under Order Entry > New Diagnostic Order DENOMINAT = # of Diagnostic Orders entered into Falcon for this provider in the reporting period (Order Entry > Diagnostic Orders. Use CPT codes between ) NUMERAT = Image documents uploaded within the reporting period with one of the qualifying categories and file types. (NOTE: DOES NOT match on patient any image can be used to meet the numerator regardless of patient or provider that uploaded the image) Files types: Gif, jpg, pdf, png, tif, tiff, jpeg Categories: Cardiac, EKG, Imaging, Pathology, Radiology or Xray MS #4 FAMILY HEALTH HISTY 20% or Excluded More than 20 percent of all unique patients seen by the EP during the EHR reporting period have a structured data entry for one or more first-degree relatives. EXCLUSION: Any EP who has no office visits during the EHR reporting period. Complete the FHH (Family Health History) grid on the left side of echarting for Office patients and Dialysis patients that are seen during the reporting period. DENOMINAT = Number of unique patient Office and Dialysis encounters during the reporting period NUMERAT = Number of patients in the denominator that have family health history entered in Falcon NOTE: Selecting Other does not count for MU v /30/2014 Page 10 of 13

11 CQMs Required In 2014, all providers, regardless of whether they are in Stage 1 or Stage 2 of meaningful use, will be required to report on the 2014 clinical quality measures (CQMs) for eligible professionals (EPs) finalized in the Stage 2 rule. This means eligible professionals will need to report 9 measures. CQMs may be reported electronically, or via attestation. CQM Measure FALCON ACTION DEFINITION Record hypertension diagnosis on patient s problem list in Falcon. AND record patient s BP during encounter in the vitals section. NQF #0018 Controlling High Blood Pressure Percentage of patients years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period. Check the box under the Quality button on the Superbill Denominator: Patients years of age who had a diagnosis of essential hypertension within the first six months of the measurement period or any time prior to the measurement period Numerator: Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmhg and diastolic blood pressure < 90 mmhg) during the measurement period. NQF #0028 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user. Record Smoking Status in an encounter for this patient AND check the checkbox in Plan section of the encounter indicating smoking cessation was discussed Check the box under the Quality button on the Superbill Numerator: Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation counseling intervention if identified as a tobacco user Denominator: All patients aged 18 years and older NQF #0059 Diabetes: HBA1c Poor Control Percentage of patients years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period. NQF #0062 Diabetes: Urine Screening The percentage of patients years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period Record diabetes diagnosis on patient s problem list in Falcon. AND record HgbA1c result either manually in Results Inquiry or through a lab interface Check the box under the Quality button on the Superbill Record diabetes diagnosis AND either: One of these active problems: Hypertensive Chronic Kidney Disease or Glomerulonephritis and Nephrotic Syndrome or Diabetic Nephropathy or Patients years of age with diabetes with a visit during the measurement period Patients whose most recent HbA1c level (performed during the measurement period) is >9.0% Patients years of age with diabetes with a visit during the measurement period ( , ) Patients with a screening for nephropathy or evidence of nephropathy during the measurement period v /30/2014 Page 11 of 13

12 Proteinuria Active Med of: ACE inhibitor or ARB Procedure documented: Kidney transplant, Vascular Access for Dialysis Dialysis Services Lab Test result for: Microalbumin NQF #0064 Diabetes: Low Density Lipoprotein (LDL) Management Percentage of patients years of age with diabetes whose LDL-C was adequately controlled (<100 mg/dl) during the measurement period. Record diabetes diagnosis on patient s problem list in Falcon. AND record LDL Cholesterol level result either manually in Results Inquiry or through a lab interface Check the box under the Quality button on the Superbill Patients years of age with diabetes with a visit during the measurement period Patients whose most recent LDL-C level performed during the measurement period is < 100 mg/dl NQF #0419 Documentation of Current Medications in the Medical Record Percentage of specified visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications to the best of his/her knowledge and ability. This list must include ALL prescriptions, over-thecounters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration. NQF #0421 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Percentage of patients aged 18 years and older with a calculated BMI in the past six months or during the current reporting period documented in the medical record AND if the most recent BMI is outside of normal parameters, a Check the checkbox in the Plan section of the encounter indicating that medications were documented Check the checkbox under the Quality button on the Superbill All visits occurring during the 12 month reporting period for patients aged 18 years and older before the start of the measurement period Eligible professional attests to documenting a list of current medications to the best of his/her knowledge and ability. This list must include ALL prescriptions, over-the-counters, herbals and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications name, dosages, frequency and route of administration Check the checkbox in the Medication section in the encounter Current medications documented Initial Patient Population 1: All patients 65 years of age and older before the beginning of the measurement period with at least one eligible encounter during the measurement period NOT INCLUDING encounters where the patient is receiving palliative care, refuses BMI measurement, the patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient s health status, or there is any other reason documented in the medical v /30/2014 Page 12 of 13

13 follow-up plan is documented within the past six months or during the current reporting period. Normal Parameters: Age 65 years and older BMI 23 and < 30 Age years BMI 18.5 and < 25 record by the provider explaining why BMI measurement was not appropriate. Initial Patient Population 2: All patients 18 through 64 years before the beginning of the measurement period with at least one eligible encounter during the measurement period NOT INCLUDING encounters where the patient is receiving palliative care, refuses BMI measurement, the patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient s health status, or there is any other reason documented in the medical record by the provider explaining why BMI measurement was not appropriate. NQF #TBD CMS22v1 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated NQF #TBD CMS65v2 Hypertension: Improvement in Blood Pressure Percentage of patients aged years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period Check the checkbox under the Quality button on the Superbill Record hypertension diagnosis on patient s problem list in Falcon. AND record patient s BP during encounter in the vitals section. Falcon will calculate if there is an improvement in BP. If only one BP is recorded during the reporting period, the patient is NOT put in the numerator and BP is assumed not improved. Patients with a documented calculated BMI during the encounter or during the previous six months, AND when the BMI is outside of normal parameters, follow-up is documented during the encounter or during the previous six months of the encounter with the BMI outside of normal parameters Percentage of patients aged 18 years and older before the start of the measurement period Patients who were screened for high blood pressure AND a recommended follow-up plan is documented as indicated if the blood pressure is pre-hypertensive or hypertensive All patients aged years of age, who had at least one outpatient visit in the first six months of the measurement year, who have a diagnosis of hypertension documented during that outpatient visit, and who have uncontrolled baseline blood pressure at the time of that visit Patients whose follow-up blood pressure is at least 10 mmhg less than their baseline blood pressure or is adequately controlled. If a follow-up blood pressure reading is not recorded during the measurement year, the patient s blood pressure is assumed not improved v /30/2014 Page 13 of 13