Andrew C. Bledsoe, MBA, CHPA, PCMH CCE Executive Director. Northeast KY Regional Health Information Organization.

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1 Andrew C. Bledsoe, MBA, CHPA, PCMH CCE Executive Director Northeast KY Regional Health Information Organization

2 NCQA Program Setup Standards Six Standards Outline Program Elements Six Must Pass Factors Must meet 50% AND ALL Critical Factors

3 Recognition Levels Level Points Must-Pass Elements Level Level Level

4 2014 NCQA Standards PCMH 1 PCMH 2 PCMH 3 PCMH 4 PCMH 5 PCMH 6 Patient Centered Access Team Based Care Population Health Management Care Management and Support Care Coordination and Care Transition Performance Measurement and Quality Improvement

5 Standards Summary Standard PCMH 1: Patient-Centered Access PCMH 2: Team-based Care PCMH 3: Population Health Management Summary of Requirements provides 24/7 access to team-based care for both routine and urgent needs of patients/families/caregivers provides continuity of care using culturally and linguistically appropriate, team-based approaches provides evidence-based decisions support and proactive care reminders based on complete patient information, health assessment and clinical data

6 Standards Summary Standard PCMH 4: Care Management and Support PCMH 5: Care Coordination and Care Transitions PCMH 6: Performance Measurement and Quality Improvement Summary of Requirements The Practice systematically identifies individual patient and plans, manages and coordinates care, based on need. systematically tracks tests and coordinates care across specialty care, facility-based care and community organizations. uses performance date to identify opportunities for improvement and acts to improve clinical quality, efficiency and patient experience.

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8 Sample Element P C M H 3 : P o p u l a t i o n H e a l t h M a n a g e m e n t Element D: Use Data for Population Management At least annually the practice proactively identifies populations of patients and reminds them, or their families/caregivers, of needed care based on patient information, clinical data, health assessments and evidence-based guidelines including: 1) At least two different preventive care services 2) At least two different immunizations 3) At least three different chronic or acute care services 4) Patient not recently seen by the practice 5) Medication monitoring or alert 100% meets 4-5 factors 75% meets 3 factors 50% meets 2 factors 25% meets 1 factor 0% meets 0 factors 5 Points 3.75 Points 2.5 Points 0 Points 0 Points

9 Stage 2 Core MU Measures 1) CPOE 2) erx 3) Demographics 4) Vital Signs 5) Smoking Status 6) Clinical Decision Support 7) View, Download and Transmit 8) Clinical Summaries 9) Privacy and Security 10) Lab-test Results 11) List of Patients 12) Patient Reminders 13) Patient Education 14) Medication Reconciliation 15) Summary of Care/Transitions of Care 16) Immunization Registry 17) Secure Electronic Messaging

10 MU Core Measure 1 CPOE - 60% Medications - 30% Lab - 30% Radiology PCMH 4: Care Management and Support Element D: Use Electronic Prescribing 3.0 Points 1. More that 50% of eligible prescriptions written by the practice are compared to drug formularies and electronically sent to pharmacies 2. Enters electronic medication orders in the medical record for more that 60 percent of medications 3. Performs patient-specific checks for drug-drug and drug-allergy interactions 4. Alerts prescribers to generic alternatives PCMH 5: Care Coordination and Care Transitions Element A: Test Tracking and Follow-Up 6.0 Points 1. Tracks lab tests until results are available, flagging and following up on overdue results. (CRITICAL FACTOR) 2. Tracks imaging tests until results are available, flagging and following up on overdue results. (CRITICAL FACTOR) 3. Flags abnormal lab results, bringing them to the attention of the clinician. 4. Flags abnormal imaging results, bringing them to the attention of the clinician. 5. Notifies patients/families of normal and abnormal lab and imaging test results. 6. Follows up with the inpatient facility about newborn hearing and newborn blood-spot screening (N/A for adults). 7. More that 30% of laboratory orders are electronically recorded in the patient record 8. More that 30 %of the radiology orders are electronically recorded in the patient record 9. Electronically incorporates more than 55% of all clinical lab test results into structured fields in medical record. 10. More than 10% of scans and test that result in an image are accessible electronically.

11 MU Core Measure 2 erx - 50% Generate and transmit prescriptions electronically PCMH 4: Care Management and Support Element D: Use Electronic Prescribing 3.0 Points 1. More that 50% of eligible prescriptions written by the practice are compared to drug formularies and electronically sent to pharmacies 2. Enters electronic medication orders in the medical record for more that 60 percent of medications 3. Performs patient-specific checks for drug-drug and drug-allergy interactions 4. Alerts prescribers to generic alternatives 100% meets 4 factors 75% meets 3 factors 50% meets 2 factors 25% meets 1 factor 0% meets 0 factors 3 Points 2.25 Points 1.5 Points.75 Points 0 Points

12 MU Core Measure 3 Record Demographics - 80% -Language -Sex -Race -Ethnicity -DoB PCMH 3: Population Health Management Element A: Patient Information 3.0 Points Practice records as structured data for more that 80% of patients the following: 1. Date of Birth 2. Sex 3. Race 4. Ethnicity 5. Preferred Language 6. Telephone numbers 7. address 8. Occupation 9. Dates of previous clinical visits 10. Legal guardian/health care proxy 11. Primary caregiver 12. Presence of advance directives 13. Health insurance information 14. Name and contact information of other health care professionals involved in patients care. 100% meets factors 75% meets 8-9 factors 50% meets 5-7 factors 25% meets 3-4 factor 0% meets 0-2 factors 3 Points 2.25 Points 1.5 Points.75 Points 0 Points

13 MU Core Measure 4 Record Vitals - 80% -Height/length -Weight -Blood Pressure -BMI -Display growth chart PCMH 3: Population Health Management Element B: Clinical Data 4.0 Points uses an electronic system with the functionality in factors 6 and 7 and records the information in factors 1-5 and 8-11 as structured data. 1. An up-to-date problem list with current and active diagnoses for 80% of patients 2. Allergies, including medication allergies and adverse reactions for more than 80% of patients 3. Blood pressure, with the date of update, for more than 80% of patients 3 and up. 4. Height/length for more than 80% of patients 5. Weight for more than 80% of patients 6. System calculates and displays BMI 7. System plots and displays growth charts 8. Status of tobacco use for patients 13 years and older for more than 80% of patients 9. List of prescription medications with date of updates for more than 80% of patients 10.More than 20% of patients have family history recorded as structured data 11.At least one electronic progress note created, edited and signed by an eligible professional for more than 30 % of patient with at least one office visit.

14 MU Core Measure 5 Record Smoking Status - 80% -Patients age 13 and up PCMH 3: Population Health Management Element B: Clinical Data 4.0 Points uses an electronic system with the functionality in factors 6 and 7 and records the information in factors 1-5 and 8-11 as structured data. 1. An up-to-date problem list with current and active diagnoses for 80% of patients 2. Allergies, including medication allergies and adverse reactions for more than 80% of patients 3. Blood pressure, with the date of update, for more than 80% of patients 3 and up. 4. Height/length for more than 80% of patients 5. Weight for more than 80% of patients 6. System calculates and displays BMI 7. System plots and displays growth charts 8. Status of tobacco use for patients 13 years and older for more than 80% of patients 9. List of prescription medications with date of updates for more than 80% of patients 10.More than 20% of patients have family history recorded as structured data 11.At least one electronic progress note created, edited and signed by an eligible professional for more than 30 % of patient with at least one office visit.

15 MU Core Measure 6 -Implement 5 Clinical Decision Support Rules -Enable drug-drug and drug to allergy interaction checks PCMH 4: Care Management and Support Element D: Use Electronic Prescribing 3.0 Points 1. More that 50% of eligible prescriptions written by the practice are compared to drug formularies and electronically sent to pharmacies 2. Enters electronic medication orders in the medical record for more that 60 percent of medications 3. Performs patient-specific checks for drug-drug and drug-allergy interactions 4. Alerts prescribers to generic alternatives 100% 75% 50% 25% 0% meets 4 factors meets 3 factors meets 2 factors meets 1 factor meets 0 factors 3 Points 2.25 Points 1.5 Points.75 Points 0 Points

16 MU Core Measure 7 Provide patients ability to View, Download and Transmit their ephi - 50% available - 5% viewed PCMH 1: Patient-Centered Access Element C: Electronic Access 2.0 Points The following information and services are provided to patients/families/caregivers, as specified, through a secure electronic system. 1. More than 50% of patients have online access to their health information within four business days of when the information is available to the practice. 2. More than 5% of patients view, and are provided the capability to download, their health information or transmit their health information to a third party. 3. Clinical summaries are provided within 1 business day for more than 50% of office visits. 4. A secure message was sent to more than 5% of patients. 5. Patients have two-way communication with the practice. 6. Patients can request appointments, prescription refills, referrals and test results.

17 MU Core Measure 8 Provide clinical summaries to patients for each office visit within one business day -50% PCMH 1: Patient-Centered Access Element C: Electronic Access 2.0 Points The following information and services are provided to patients/families/caregivers, as specified, through a secure electronic system. 1. More than 50% of patients have online access to their health information within four business days of when the information is available to the practice. 2. More than 5% of patients view, and are provided the capability to download, their health information or transmit their health information to a third party. 3. Clinical summaries are provided within 1 business day for more than 50% of office visits. 4. A secure message was sent to more than 5% of patients. 5. Patients have two-way communication with the practice. 6. Patients can request appointments, prescription refills, referrals and test results.

18 MU Core Measure 9 Protect electronic health information (Privacy and Security) PCMH 6: Performance Measurement and Quality Improvement Element G: Use Certified EHR Technology 0.0 Points 1. uses an EHR system that has been certified and issued a CMS certification ID. 2. conducts a security risk analysis and implement updates as necessary. 3. demonstrates the capability to submit electronic syndromic surveillance data to public health agencies electronically. 4. demonstrates the capability to identify and report cancer cases to a public health central cancer registry electronically. 5. demonstrates the capability to identify and report specific cases to a specialized registry electronically. 6. reports clinical quality measures to Medicare or Medicaid agency. 7. demonstrates the capability to submit data to immunization registries or immunization information systems electronically. 8. has access to a health information exchange. 9. has bidirectional exchange with a health information exchange. 10. generates lists of patients, and based on their preferred method of communication, proactively reminds more than 10% of patients/families/caregivers about needed preventive/follow-up care.

19 MU Core Measure 10 Incorporate clinical lab-test results into EHR as structured data. - 55% PCMH 5: Care Coordination and Care Transitions Element A: Test Tracking and Follow-Up 6.0 Points 1. Tracks lab tests until results are available, flagging and following up on overdue results. (CRITICAL FACTOR) 2. Tracks imaging tests until results are available, flagging and following up on overdue results. (CRITICAL FACTOR) 3. Flags abnormal lab results, bringing them to the attention of the clinician. 4. Flags abnormal imaging results, bringing them to the attention of the clinician. 5. Notifies patients/families of normal and abnormal lab and imaging test results. 6. Follows up with the inpatient facility about newborn hearing and newborn blood-spot screening (N/A for adults). 7. More that 30% of laboratory orders are electronically recorded in the patient record 8. More that 30 %of the radiology orders are electronically recorded in the patient record 9. Electronically incorporates more than 55% of all clinical lab test results into structured fields in medical record. 10. More than 10% of scans and test that result in an image are accessible electronically.

20 MU Core Measure 11 Generate lists of patients by specific condition PCMH 3: Population Health Management Element D: Use data for Population Management (MUST PASS) 5.0 Points At least annually the practice proactively identifies populations of patients and reminds them, or their families/caregivers of needed care based on patient information. 1. At least two different preventive care services 2. At least two different immunizations 3. At least three different chronic or acute care services 4. Patients not recently seen by the practice 5. Medication monitoring or alert.

21 MU Core Measure 12 Send reminders to patients for preventive/followup care - 10 % PCMH 6: Performance Measurement and Quality Improvement Element G: Use Certified EHR Technology 0.0 Points 1. uses an EHR system that has been certified and issued a CMS certification ID. 2. conducts a security risk analysis and implement updates as necessary. 3. demonstrates the capability to submit electronic syndromic surveillance data to public health agencies electronically. 4. demonstrates the capability to identify and report cancer cases to a public health central cancer registry electronically. 5. demonstrates the capability to identify and report specific cases to a specialized registry electronically. 6. reports clinical quality measures to Medicare or Medicaid agency. 7. demonstrates the capability to submit data to immunization registries or immunization information systems electronically. 8. has access to a health information exchange. 9. has bidirectional exchange with a health information exchange. 10. generates lists of patients, and based on their preferred method of communication, proactively reminds more than 10% of patients/families/caregivers about needed preventive/follow-up care.

22 MU Core Measure 13 Identify and provide patient specific education resources to patient - 10% PCMH 4: Care Management and Support Element E: Support Self-Care and Shared Decision Making 5.0 Points has, and demonstrates us of, materials to support patients and families/caregivers in self-management and shared decision making. 1. Uses an EHR to identify patient-specific education resources and provide them to more than 10% of patients. 2. Provides educational materials and resources to patients. 3. Provides self-management tools to record self-care results. 4. Adopts shared decision making aids. 5. Offers or refers patients to structured health education programs, such as group classes or peer support. 6. Maintains a current resource list of five topics or key community service areas of importance to the patient population including services offered outside the practice and its affiliates. 7. Assesses usefulness of identified community resources.

23 MU Core Measure 14 Perform Medication Reconciliation as relevant - 50% PCMH 4: Care Management and Support Element C: Medication Management 4.00 Points has a process for managing medications, and systematically implements the process in the following ways. 1. Reviews and reconciles medications for more than 50% of patients received from care transitions. (CRITICAL FACTOR) 2. Reviews and reconciles medications with patients/families for more than 80% of care transitions. 3. Provides information about new prescriptions to more than 80% of patients/families/caregivers. 4. Assesses understanding of medications for more than 50% of patients/families/caregivers, and dates the assessment. 5. Assesses response to medications and barriers to adherence for more than 50% of patients, and dates the assessment. 6. Documents over-the-counter medications, herbal therapies and supplements for more than 50% of patients, and dates updates.

24 MU Core Measure 15 Provide Summary of Care record for transitions in care or referrals: a) Provide summary of care document 50% b) Provide summary of care document electronically 10% c) Provide summary of care document to another provider on different EHR - Once PCMH 5: Care Coordination and Care Transitions Element B: Coordinate Care Transitions (MUST PASS) 6.00 Points : 1. Considers available performance information on consultants/specialists when making referral recommendations. 2. Maintains formal and information agreements with a subset of specialists based on established criteria 3. Maintains agreements with behavioral healthcare providers. 4. Integrates behavioral healthcare providers within the practice site. 5. Gives the consultant or specialist the clinical question, the required timing and the type of referral. 6. Gives the consultant or specialist pertinent demographic and clinical data, including test results and the current care plan. 7. Has the capacity for electronic exchange of key clinical information and provides an electronic summary of care record to another provider for more than 50% of referrals. 8. Tracks referrals until the consultant or specialist's report is available, flagging and following up on overdue reports. (CRITICAL FACTOR) 9. Documents co-management arrangements in the patients medical record 10. Asks patients/families about self-referrals and requesting reports from clinicians.

25 MU Core Measure 15 Provide Summary of Care record for transitions in care or referrals: a) Provide summary of care document 50% b) Provide summary of care document electronically 10% c) Provide summary of care document to another provider on different EHR - Once PCMH 5: Care Coordination and Care Transitions Element C: Coordinate Care Transitions 6.00 Points : 1. Proactively identifies patients with unplanned hospital admissions and emergency department visits. 2. Shares clinical information with admitting hospitals and emergency departments. 3. Consistently obtains patient discharge summaries from the hospital and other facilities 4. Proactively contacts patients/families for appropriate follow-up care within an appropriate period following a hospital admission or emergency department visit. 5. Exchanges patient information with the hospital during a patient s hospitalization. 6. Obtains proper consent for release of information and has a process for secure exchange of information and for coordination of care with community partners. 7. Exchanges key clinical information with facilities and provides an electronic summary-of-care record to another care facility for more than 50 percent of patient transitions of care.

26 MU Core Measure 16 Submit electronic data to state Immunization Registry PCMH 6: Performance Measurement and Quality Improvement Element G: Use Certified EHR Technology 0.0 Points 1. uses an EHR system that has been certified and issued a CMS certification ID. 2. conducts a security risk analysis and implement updates as necessary. 3. demonstrates the capability to submit electronic syndromic surveillance data to public health agencies electronically. 4. demonstrates the capability to identify and report cancer cases to a public health central cancer registry electronically. 5. demonstrates the capability to identify and report specific cases to a specialized registry electronically. 6. reports clinical quality measures to Medicare or Medicaid agency. 7. demonstrates the capability to submit data to immunization registries or immunization information systems electronically. 8. has access to a health information exchange. 9. has bidirectional exchange with a health information exchange. 10. generates lists of patients, and based on their preferred method of communication, proactively reminds more than 10% of patients/families/caregivers about needed preventive/follow-up care.

27 MU Core Measure 17 Use Secure Electronic Messaging to communicate with Patients - 5% PCMH 1: Patient-Centered Access Element C: Electronic Access 2.0 Points The following information and services are provided to patients/families/caregivers, as specified, through a secure electronic system. 1. More than 50% of patients have online access to their health information within four business days of when the information is available to the practice. 2. More than 5% of patients view, and are provided the capability to download, their health information or transmit their health information to a third party. 3. Clinical summaries are provided within 1 business day for more than 50% of office visits. 4. A secure message was sent to more than 5% of patients. 5. Patients have two-way communication with the practice. 6. Patients can request appointments, prescription refills, referrals and test results.

28 Stage 2 Menu MU Measures 1) Syndromic Surveillance 2) Electronic Notes 3) Imaging Results 4) Family Health History 5) Cancer Registry 6) Specialized Registry

29 MU Menu Measure 1 Submit Syndromic Surveillance data to public health agency PCMH 6: Performance Measurement and Quality Improvement Element G: Use Certified EHR Technology 0.0 Points 1. uses an EHR system that has been certified and issued a CMS certification ID. 2. conducts a security risk analysis and implement updates as necessary. 3. demonstrates the capability to submit electronic syndromic surveillance data to public health agencies electronically. 4. demonstrates the capability to identify and report cancer cases to a public health central cancer registry electronically. 5. demonstrates the capability to identify and report specific cases to a specialized registry electronically. 6. reports clinical quality measures to Medicare or Medicaid agency. 7. demonstrates the capability to submit data to immunization registries or immunization information systems electronically. 8. has access to a health information exchange. 9. has bidirectional exchange with a health information exchange. 10. generates lists of patients, and based on their preferred method of communication, proactively reminds more than 10% of patients/families/caregivers about needed preventive/follow-up care.

30 MU Menu Measure 2 Record Electronic Notes in patient records - 30% PCMH 3: Population Health Management Element B: Clinical Data 4.0 Points uses an electronic system with the functionality in factors 6 and 7 and records the information in factors 1-5 and 8-11 as structured data. 1. An up-to-date problem list with current and active diagnoses for 80% of patients 2. Allergies, including medication allergies and adverse reactions for more than 80% of patients 3. Blood pressure, with the date of update, for more than 80% of patients 3 and up. 4. Height/length for more than 80% of patients 5. Weight for more than 80% of patients 6. System calculates and displays BMI 7. System plots and displays growth charts 8. Status of tobacco use for patients 13 years and older for more than 80% of patients 9. List of prescription medications with date of updates for more than 80% of patients 10.More than 20% of patients have family history recorded as structured data 11.At least one electronic progress note created, edited and signed by an eligible professional for more than 30 % of patient with at least one office visit.

31 MU Menu Measure 3 Imaging Results are available in the EHR system - 10% PCMH 5: Care Coordination and Care Transitions Element A: Test Tracking and Follow-Up 6.0 Points 1. Tracks lab tests until results are available, flagging and following up on overdue results. (CRITICAL FACTOR) 2. Tracks imaging tests until results are available, flagging and following up on overdue results. (CRITICAL FACTOR) 3. Flags abnormal lab results, bringing them to the attention of the clinician. 4. Flags abnormal imaging results, bringing them to the attention of the clinician. 5. Notifies patients/families of normal and abnormal lab and imaging test results. 6. Follows up with the inpatient facility about newborn hearing and newborn blood-spot screening (N/A for adults). 7. More that 30% of laboratory orders are electronically recorded in the patient record 8. More that 30 %of the radiology orders are electronically recorded in the patient record 9. Electronically incorporates more than 55% of all clinical lab test results into structured fields in medical record. 10. More than 10% of scans and test that result in an image are accessible electronically.

32 MU Menu Measure 4 Record Family Health History as structured data - 20% PCMH 3: Population Health Management Element B: Clinical Data 4.0 Points uses an electronic system with the functionality in factors 6 and 7 and records the information in factors 1-5 and 8-11 as structured data. 1. An up-to-date problem list with current and active diagnoses for 80% of patients 2. Allergies, including medication allergies and adverse reactions for more than 80% of patients 3. Blood pressure, with the date of update, for more than 80% of patients 3 and up. 4. Height/length for more than 80% of patients 5. Weight for more than 80% of patients 6. System calculates and displays BMI 7. System plots and displays growth charts 8. Status of tobacco use for patients 13 years and older for more than 80% of patients 9. List of prescription medications with date of updates for more than 80% of patients 10.More than 20% of patients have family history recorded as structured data 11.At least one electronic progress note created, edited and signed by an eligible professional for more than 30 % of patient with at least one office visit.

33 MU Menu Measure 5 Capability to identify and report cancer cases to public health cancer registry MU Menu Measure 6 Capability to identify and report specific cases to public health specialized registry PCMH 6: Performance Measurement and Quality Improvement Element G: Use Certified EHR Technology 0.0 Points 1. uses an EHR system that has been certified and issued a CMS certification ID. 2. conducts a security risk analysis and implement updates as necessary. 3. demonstrates the capability to submit electronic syndromic surveillance data to public health agencies electronically. 4. demonstrates the capability to identify and report cancer cases to a public health central cancer registry electronically. 5. demonstrates the capability to identify and report specific cases to a specialized registry electronically. 6. reports clinical quality measures to Medicare or Medicaid agency. 7. demonstrates the capability to submit data to immunization registries or immunization information systems electronically. 8. has access to a health information exchange. 9. has bidirectional exchange with a health information exchange. 10. generates lists of patients, and based on their preferred method of communication, proactively reminds more than 10% of patients/families/caregivers about needed preventive/follow-up care.

34 Questions? Andrew C. Bledsoe MBA, PCMH CCE, CHPS, CHTS-PW Executive Director Northeast KY RHIO

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