PPC 8: Performance Reporting and Improvement Element E: Reporting Standardized Measures
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1 PPC 8: Performance Reporting and Improvement Element E: Reporting Standardized Measures measures and has the capability to report on more than 10 nationally approved performance measures. We have the ability to report on current measures and can program new measures as the national measure sets evolve. Most of our measures are from the National Health Disparities Collaborative or required as part of our grant as a Federally Qualified Health Center. Measures from the National Quality Forum (NQF) are associated below: NQF # 0001 Title: Status: Steward(s): Descripti Asthma assessment AUG 10, 2009 American Medical Association - Physician Consortium for Performance Improvement Percentage of patients who were evaluated during at least one office visit for the frequency (numeric) of daytime and nocturnal asthma symptoms NQF # 0013 Title: Blood pressure measurement SEP 12, 2010 Steward(s): American Medical Association - Physician Consortium for Performance Improvement Percentage of patient visits with blood pressure measurement recorded among all patient visits for patients Descripti aged > 18 years with diagnosed hypertension. PCMH Recognition Application Page 1 of 14
2 NQF # 0031 Title: Breast Cancer Screening OCT 27, 2010 Descripti Percentage of eligible women who receive a mammogram in a two year period PCMH Recognition Application Page 2 of 14
3 NQF # 0005 Title: CAHPS Clinician/Group Surveys - (Adult Primary Care, Pediatric Care, and Specialist Care Surveys) JUL 01, 2007 Steward(s): Agency for Healthcare Research and Quality Adult Primary Care Survey: 37 core and 64 supplemental question survey of adult outpatient primary care patients. Pediatric Care Survey: 36 core and 16 supplemental question survey of outpatient pediatric care patients. Descripti Specialist Care Survey: 37 core and 20 supplemental question survey of adult outpatients specialist care patients. Level of analysis for each of the 3 surveys: group practices, sites of care, and/or individual clinicians PCMH Recognition Application Page 3 of 14
4 NQF # 0032 Title: Cervical Cancer Screening AUG 10, 2009 Percentage of women years of age, who received one or more Pap tests during the measurement year Descripti or the two years prior to the measurement year PCMH Recognition Application Page 4 of 14
5 NQF # 0038 Title: Childhood Immunization Status AUG 10, 2009 Percentage of children 2 years of age who had four DtaP/DT, three IPV, one MMR, three H influenza type B, Descripti three hepatitis B, one chicken pox vaccine (VZV) and four pneumococcal conjugate vaccines by their second birthday. The measure calculates a rate for each vaccine and two separate combination rates PCMH Recognition Application Page 5 of 14
6 NQF # 0091 Title: COPD: spirometry evaluation AUG 10, 2009 Steward(s): American Medical Association - Physician Consortium for Performance Improvement Descripti Percentage of patients with COPD who had a spirometry evaluation documented PCMH Recognition Application Page 6 of 14
7 NQF # 0575 Title: Comprehensive Diabetes Care: HbA1c control (<8.0%) DEC 04, 2009 The percentage of members years of age with diabetes (type 1 and type 2) who had HbA1c control Descripti (<8.0%). PCMH Recognition Application Page 7 of 14
8 NQF # 0018 Title: Controlling High Blood Pressure SEP 12, 2010 Descripti The percentage of members years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the measurement year. Use the Hybrid Method for this measure. NQF # 0055 Title: Diabetes: Eye exam AUG 10, 2009 Percentage of adult patients with diabetes aged years who received a dilated eye exam or seven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist or imaging validated to match diagnosis from these photos during the reporting year, or during the prior year, if patient Descripti is at low risk** for retinopathy **Patient is considered low risk if the following criterion is met: has no evidence of retinopathy in the prior year PCMH Recognition Application Page 8 of 14
9 NQF # 0062 Title: Diabetes: Urine protein screening AUG 10, 2009 Descripti Percentage of adult diabetes patients aged years with at least one test for microalbumin during the measurement year or who had evidence of medical attention for existing nephropathy (diagnosis of nephropathy or documentation of microalbuminuria or albuminuria) NQF # 0059 Title: Hemoglobin A1c management AUG 10, 2009 Percentage of adult patients with diabetes aged years with most recent A1c level greater than 9.0% Descripti (poor control) PCMH Recognition Application Page 9 of 14
10 NQF # 0057 Title: Hemoglobin A1c testing AUG 10, 2009 Descripti Percentage of adult patients with diabetes aged years receiving one or more A1c test(s) per year NQF # 0617 Title: High Risk for Pneumococcal Disease - Pneumococcal Vaccination DEC 04, 2009 Steward(s): ActiveHealth Management Percentage of patients age 5-64 with a high risk condition or age 65 years and older who received the Descripti pneumococcal vaccine PCMH Recognition Application Page 10 of 14
11 NQF # 0492 Title: Participation in a Practice-based or individual Quality Database Registry with a standard measure set. Status: Time-Limited AUG 29, 2008 Steward(s): Centers for Medicare & Medicaid Services Descripti This Registry should be capable of a. generating population based reports relating to published guideline goals or benchmarking data b. providing comparisons to the practitioner c. providing feedback that is related to guideline goals d. capturing data for one or more chronic disease conditions (i.e. diabetes) or preventive care measures (i.e. USPTF recommendations) for all patients eligible for the measures EHS meets all the requirements for NQF#0492 NQF # 0036 Title: Use of appropriate medications for people with asthma AUG 10, 2009 Percentage of patients who were identified as having persistent asthma during the measurement year and the Descripti year prior to the measurement year and who were dispensed a prescription for either an inhaled corticosteroid or acceptable alternative medication during the measurement year PCMH Recognition Application Page 11 of 14
12 PCMH Recognition Application Page 12 of 14
13 EHS allows us the ability to use Business Objects to report on a wide variety of items. We have the expertise in-house to build reports based on very specific guidelines. EHS includes queries associated with standard diagnosis (ICD) and procedure (CPT) codes, prescribed medictions, lab tests and results, radiology tests and results, vital signs and more. Here are the major categories available for report building: PCMH Recognition Application Page 13 of 14
14 Here is a sample query. You just drag from the list on the left and drop on the right. The top section is for the results you want in your report. The bottom section is the selection conditions for the query. PCMH Recognition Application Page 14 of 14
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