All materials © 2013, National Committee for Quality Assurance

Standards Workshop Part 2

Patient-Centered Specialty Practice (PCSP) Recognition

Program

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Agenda Part 1• Content of PCSP Standards and

Guidelines– Standards 1 – 3– Documentation Examples*

Agenda Part 2• Content of PCSP Standards and

Guidelines– Standards 4 – 6– Documentation Examples*

*Examples in the presentation only illustrate the element intent. They are NOT definitive nor the only methods of documenting how the requirements may be met.

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PCSP 4: Plan and Manage Care

Intent• Collaborate with

patient/family/caregiver and PCP to develop and implement care plan

• Review and reconcile medications

• E-prescribe

Meaningful Use• Use EHR to identify

patient education resources

• Review and reconcile medications

• Use an e-prescribing system to write and transmit prescriptions

• Compare meds. With formularies, check for generics, drug-drug and drug-allergy interactions

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PCSP 4: Plan and Manage Care

Elements• PCSP 4A: Care Planning

and Self-Care Support• PCSP 4B: Medication

Management - MUST PASS

• PCSP 4C: Use of Electronic Prescribing

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PCSP 4A: Care Planning and Self-Support

The practice provides the following care management and self-care support for practice-specific conditions:1. Conduct pre-visit preparations 2. Assess patient risk status to identify patients

needing additional support and services 3. Collaborate with the patient/family/caregiver

to develop a specialist’s plan of care that includes patient’s goals, potential barriers/self-care ability - CRITICAL FACTOR

4. Share specialist’s plan of care including recommendations for self-care support with the PCP and referring clinician - CRITICAL FACTOR

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PCSP 4A: Care Planning and Self-Support

The practice provides the following care management and self-care support for practice-specific conditions:5. Give the patient/family/caregiver a written

specialist’s plan of care including self-care recommendations.

6. Provide educational resources or refer patients/families/caregivers to assist in self-management

7. Assess/address barriers when patient has not met treatment goals

8. Use an EHR to identify patient-specific education resources and provide to more than 10 percent of patients+

+ Stage 2 Core Meaningful Use Requirement  

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PCSP 4A: Care Planning and Self-Support

• 11 Points• Scoring

– 100% - 6-8 factors, including Factors 3 and 4– 75% - 4-5 factors, including Factors 3 and 4– 50% - 2-3 factors, including Factors 3 and 4– 25% - No scoring option– 0% - 0-1 factor, or does not meet Factors 3 and 4

•   Documentation– Factors 1-7: Written process and examples – Factor 8: Report with numerator, denominator and

percentage

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PCSP 4A: Example Pre-visit Form Patients complete form pre-visit: Focus of today’s visit Medications Allergies Pain assessment Flu vaccine Depression assessment Recent ER visit

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PCSP 4A: Example Patient Education

Prenatal Care: Steps Toward a Healthy PregnancyPrenatal Session #1

PROGRAM: Comprehensive Perinatal Services Program TIME: 1-1 ½ Hours

OBJECTIVESBy the end of the session, the participant will be able to:

1. Identify basic anatomy of human reproductive system2. Identify common discomforts of pregnancy including aspects of fetal

growth and development3. Identify danger signs during pregnancy and action to take during complications4. Identify lab tests including the importance of ultrasound5. Understand the importance of Oral health during pregnancy

Practice must also attach a complete set of education materials that could be provided to the patient.

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PCSP 4B: Medication Management

The practice has a process and demonstrates that it systematically manages medications prescribed by the practice in the following ways: 1. Reviews and reconciles medications for

more than 50 percent of patients received from another care setting or a relevant visit+

2. Provides information about new prescriptions from specialty practice to patients/families/caregivers.

3. Coordinates medication management and reconciliation with the PCP, referring clinician and patient/family/caregiver

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PCSP 4B: Medication Management

The practice has a process and demonstrates that it systematically manages medications prescribed by the practice in the following ways: 4. Assesses patient/family/caregiver

understanding of medications from specialty practice

5. Assesses patient response to medications from specialty practice and barriers to adherence

6. Documents over-the-counter medications, herbal therapies and supplements

+ Stage 2 Core Meaningful Use Requirement

 

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PCSP 4B: Medication Management

• Must Pass• 5 Points• Scoring

– 100% - 5-6 factors– 75% - 4 factors– 50% - 3 factors– 25% - 2 factors– 0% - 0-1 factors

• Documentation: – Factor 1: Report with numerator, denominator and

percentage– Factors 2-6: Documented process and three examples for

each factor

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PCSP 4B: Example Medication Reconciliation

Reconcile meds. at each visit for patient safety and effectiveness of medications

1. Pts. bring list or meds. to each visit; reminded when appt. scheduled; signs in pt. rooms

2. Med. asst. reviews meds. at each visit3. MD reviews current meds.; discusses

pt. concerns4. Motivational interviewing/shared

decision-making to help with risks/benefits of meds.

5. MD/staff teach pt. about med. administration

6. Follow-up call to pt. when major change to meds.

7. Check with pt. if refill requests are conflicting

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PCSP 4B: Patient Role in Med. Management

Posted in office to encourage patients to help managing their medications

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PCSP 4C: Use of Electronic Prescribing

The practice uses an electronic prescription system with the following: 1. Writes at least 75 percent of eligible prescriptions

electronically. 2. More than 50 percent of eligible prescriptions written

by the practice are compared to drug formularies and electronically sent to pharmacies+

3. Enters electronic medication orders into the medical record for more than 60 percent of patients with at least one medication in their medication list+

4. Performs patient-specific checks for drug-drug and drug-allergy interactions+

5. Alerts prescriber to generic alternatives

+ Stage 2 Core Meaningful Use Requirement

 

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PCSP 4C: Use of Electronic Prescribing

• 2 Points• Scoring

– 100% - 3-5 factors– 75% - 2 factors– 50% - 1 factor– 25% - No scoring option– 0% - 0 factors

• Documentation– Factors 1-3: Report with a numerator, denominator and

percentage– Factors 4 and 5: Report or screen shot demonstrating

capability

VS

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PCSP 4C: Example Electronic Prescription Writing

Prescription Writing Activity

Electronic 57% 2563 RxPrinted, given to patient 31% 1419 RxPrint, fax to pharmacy 1% 89 Rx_______________________________________TOTAL

Rx 4474 Rx % E-RX 89%

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PCSP 4C: Example Drug-Drug Interactions

Drug-Drug Interactions

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PCSP 4C: Example Prescription Allergy

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PCSP 4C: Example Generic Alternatives

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PCSP 5: Track and Coordinate CareIntent• Track/follow-up on

lab and imaging results

• Exchange test results with primary care

• Track/follow-up on referrals

• Coordinate with hospitals/ ERs; transition patients back to primary care

Meaningful Use• Incorporate clinical lab

test results into the medical record

• Electronically exchange clinical information with other clinicians and facilities

• Provide electronic summary of care record for referrals and care transitions

CMS EHR Incentive Programs: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html

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PCSP 5: Track and Coordinate Care

ElementsPCSP 5A: Test Tracking and Follow-

UpPCSP 5B: Referral Tracking and

Follow-UpPCSP 5C: Coordinate Care

Transitions

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PCSP 5A: Test Tracking and Follow-Up

The practice has a documented process for and demonstrates that it: 1. Requests and tracks receipt of test results

from PCP and referring clinician2. Provides PCP and referring clinician with

results of relevant tests ordered by the specialist - CRITICAL FACTOR

3. Tracks lab tests until results are available, flagging and following up on overdue results

4. Tracks imaging tests until results are available, flagging and following up on overdue results

5. Flags abnormal lab results, bringing them to the attention of the clinician

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PCSP 5A: Test Tracking and Follow-Up (cont.)

The practice has a documented process for and demonstrates that it: 6. Flags abnormal imaging results,

bringing them to the attention of the clinician

7. Patients/families/caregivers are notified about normal and abnormal lab and imaging test results

8. More than 30 percent of laboratory orders are electronically recorded in the patient record+

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PCSP 5A: Test Tracking and Follow-Up (cont.)

The practice has a documented process for and demonstrates that it: 9. More than 30 percent of radiology orders

are electronically recorded in the patient record+

10. Electronically incorporates more than 55 percent of all clinical lab test results into structured fields in medical record+

11. More than 10 percent of scans and tests that result in an image are accessible electronically+++ Stage 2 Core Meaningful Use Requirement

++ Stage 2 Menu Meaningful Use Requirement 

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PCSP 5A: Test Tracking and Follow-Up

• 5 Points• Scoring

– 100% - 6-11 factors, including factor 2– 75% - 4-5 factors, including factor 2– 50% - 3 factors, including factor 2– 25% - 1-2 factors, including factor 2– 0% - 0 factors or does not meet factor 2

• Documentation– Factors 1-7: Documented process and report with 5 days of

data or three examples of meeting the process for each factor (demonstrate the implemented process)

– Factors 8, 9, 10, 11: Report with a numerator, denominator and percentages 

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PCSP 5A: Example, Lab Process

Missing Flagging Overdue labs and FU

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PCSP 5A: Policy for Abnormal Test Results

Policy: Definitions for Abnormal Test Result Categories and Reporting Requirements for Each

• Abnormal • Abnormal

(Priority)• Abnormal (Critical)

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PCSP 5A: Example Referral Tracking

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PCSP 5A: Example Test Tracking Log

DATA COLLECTED

Patient name DOB Provider Order date Test ordered Urgency Date results received Results normal/abnormal Date results to provider Date results to patient

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PCSP 5A: Example Electronic Test Tracking

All lab and imaging tests are tracked until results are available

Overdue results are flaggedAbnormal results are

flagged

Practice tracks: Date ordered Overdue Abnormal Priority Patient name Provider Order description Last appointment Next appointment

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PCSP 5A: Example Letter for Patient Notification of Abnormal Imaging

Results

Patient/family was notified by provider of abnormal test results and given follow-up instructions

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PCSP 5B: Referral Tracking and Follow-Up

The practice coordinates referrals to other (secondary) specialists by:1. Consulting with PCP and referring clinician

and patient/family/ caregiver regarding secondary referrals

2. Giving the consultant or specialist the clinical reason for the referral and pertinent clinical information - CRITICAL FACTOR

3. Tracking the status of the referral, including required timing for receiving a specialist’s report

4. Following up to obtain specialist’s report

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PCSP 5B: Referral Tracking and Follow-Up (cont.)

The practice coordinates referrals to other (secondary) specialists by:5. Establishing and documenting agreements

with specialists in the medical record if co-management is needed

6. Asking patients/families/caregivers about self-referrals and requesting reports from clinicians

7. Assuring the PCP and original referring clinician are notified of the secondary referral results.

8. Providing an electronic summary of care record to another provider for more than 50 percent of referrals+

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PCSP 5B: Referral Tracking and Follow-Up (cont.)

The practice coordinates referrals to other (secondary) specialists by:9. Electronically transmitting a summary of care

record to another care provider for more than 10 percent of care referrals+

10.Conducting one or more successful electronic exchanges with a recipient who has technology developed by a different EHR developer or successfully tests with the CMS designated test EHR.+

+ Stage 2 Core Meaningful Use Requirement

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PCSP 5B: Referral Tracking and Follow-Up

• 6 Points• Scoring

– 100% - 8-10 factors, including Factor 2– 75% - 6-7 factors, including Factor 2– 50% - 4-5 factors, including Factor 2– 25% - 1-3 factors, including Factor 2– 0% - 0 factors

• Documentation– Factors 1-4, 6&7:

1. Documented process and2. Reports or logs showing data collection in a tracking

system – Factor 5: At least three examples– Factors 8 and 9: Report with numerator, denominator and

percentages– Factor 10: Screen shot showing capability

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PCSP 5B: Example Referral Tracking

Referral Tracking Data - 5 days• Date ordered• Referring provider• Diagnosis• Referred to• Supporting clinical information• Urgency• Type of referral• Appointment date• Date results received• Date of follow-up for missing report

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PCSP 5B: Example Co-Management Policy

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PCSP 5B: Example Follow-Up to Get Referral Report

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PCSP 5C: Coordinate Care Transitions

For conditions managed by the specialist, the practice systematically: 1. Demonstrates its process for identifying

patients with a hospital admission and patients with an emergency department visit

2. Demonstrates its process for sharing clinical information with admitting hospitals or emergency departments

3. Demonstrates its process for consistently obtaining patient discharge summaries from the hospital and other facilities cont.

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PCSP 5C: Coordinate Care Transitions (cont.)

For conditions managed by the specialist, the practice systematically: 4. Demonstrates its process for transitioning

patients back to the primary care practice5. Provides an electronic summary-of-care record

to another care facility for more than 50 percent of transitions of care+

6. Electronically transmits a summary of care record to another care setting for more than 10 percent of care transitions+

+ Stage 2 Core Meaningful Use Requirement  

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PCSP 5C: Coordinate Care Transitions

• 5 Points• Scoring

– 100% - 4-6 factors– 75% - 3 factors– 50% - 2 factors– 25% - 1 factor– 0% - 0 factors

• Documentation– Factors 1-4: 1. Documented process and 2. Three examples– Factors 5 and 6: Report with a numerator,

denominator and percentages

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PCSP 5C: Example Identifying Patients in Facilities

Practice receives admission reports electronically from hospital

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PCSP 5C: Example ER Visit Follow-Up Log

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PCSP 5C: Pediatric to Adult Transition Diabetes Care Self-Assessment

Self-assessment of worries, concerns, burdens related to diabetes and preparation for transitioning

I would like to talk about:• Challenged by diabetes burdens• Social/emotional/cognitive issues• Transition preparation/readiness

to move on

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PCSP 5C: Clinical Summary for New Health Care Team

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PCSP 6: Measure and Improve Performance

Intent• Measure clinical

performance, coordination of care, utilization affecting costs, access to care, patient experience and report performance

• Use and monitor effectiveness of quality improvement process

Meaningful UseReport:• Ambulatory quality

measures to CMS• Immunization data

to registries• Syndromic

surveillance data to public health agencies

• Cancer cases to registry

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PCSP 6: Measure and Improve Performance

Elements• PCSP 6A: Measure Performance• PCSP 6B: Measure Patient/Family

Experience• PCSP 6C: Implement & Demonstrate

Continuous Quality Improvement - MUST PASS

• PCSP 6D: Report Performance• PCSP 6E: Use Certified EHR

Technology

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PCSP 6A: Measure Performance

The practice measures or receives data on:

1. At least three clinical measures related to the practice specialty

2. Coordination of care results 3. At least two utilization measures

affecting health care costs4. Performance data stratified for

vulnerable populations (to assess disparities in care).

5. Timely access to appointments based on established criteria

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PCSP 6A: Measure Performance

• 5 Points• Scoring

– 100% - 4-5 factors– 75% - 3 factors– 50% - 1-2 factors– 25% - No scoring option– 0% - 0 factors

• Documentation– Factors 1-5: Reports showing performance

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Vulnerable Populations Defined

“Those who are made vulnerable by:

– their financial circumstances or place of residence,

– health, age, personal characteristics,– functional or developmental status, ability

to communicate effectively, and – presence of chronic illness or disability.”

Source: AHRQ

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Vulnerable vs. High Risk

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PCSP 6A: Example Chronic Care Clinical Measures

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NCQA Clinical Program Recognition

Where Can it Be Used to Meet Elements? • NCQA Clinical Recognition Programs

– Diabetes Recognition Program (DRP)– Heart/Stroke Recognition Program (HSRP)

• Credit for Clinical Program Recognition may be used for meeting some requirements if 75% of clinicians are Recognized: – PCSP 6A Factor 1 – PCSP 6C Factors 1 and 7 (if renewed), for Element

A portion– PCSP 6 D Factor 1, 2 and 3 for Element A portion

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NCQA Clinical Program RecognitionWhere Can it Be Documented to Meet

Elements?

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PCMH 6 ELEMENT A: Factor 3                     

Care Managers receive referrals from PCP'S, Hospitalists, Social Workers or family members requesting evaluation for patients to be treated at an alternative level of care (home, SNF) or in the office. The team has had a 22% success rate in saving hospital admissions since Nov 2007 .

CARE MANAGEMENT ACTIVITIES

2014 August - December

TOTAL CM REFERRALS / SAVED ADMISSIONS

2014 2014 2014 2014 2014TOTAL TO

DATE  

AUG SEPT OCT NOV DEC 2014  

TOTAL CM REFERRALS 220 202 299 221 219 1161 TOTAL CM REFERRALS

SAVED ADMISSIONS 57 53 55 49 57 271 SAVED ADMISSIONS

FAILED ATTEMPTS 5 7 2 3 3 20 FAILED ATTEMPTS

PCSP 6A: Example Measures Affecting Health Care Costs

PCSP

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PCSP 6A: Example Data for Vulnerable Populations

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PCSP 6B: Measure Patient/Family Experience

The practice obtains feedback from patients/families on their experiences with the practice and their care. 1. The practice conducts a survey (using any instrument)

to evaluate patient/family experiences on at least three of the following categories:– Access– Communication– Coordination – Self-management support

2. The practice uses CAHPS** Clinician & Group (CG) Survey Tool

3. The practice obtains feedback on experiences of vulnerable patient groups

4. The practice obtains feedback from patients/families through qualitative means**Consumer Assessment of Healthcare Providers and Systems (CAHPS)

https://www.cahps.ahrq.gov/clinician_group/

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PCSP 6B: Measure Patient/Family Experience

• 5 Points• Scoring

– 100% - 3-4 factors– 75% - No scoring option– 50% - 2 factors– 25% - 1 factor– 0% - 0 factors

• Documentation– Factors 1-4: Provides reports with summarized

results of patient feedback. A blank Survey Tool does not meet the intent of this element.

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PCSP 6B: Example of Reported CAHPS Questions for Patient Experience

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PCSP 6B: Example Patient Experience Data

Jan 2015March 2015

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2014

PCSP 6B: Example Patient Experience Survey Results

Survey questions include: Access Communication NEEDS A THIRD

CATEGORY

2014

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PCSP 6C: Implement & Demonstrate Continuous Quality Improvement

The practice demonstrates ongoing monitoring of the effectiveness of its improvement process by:1. Setting goals/acting to improve on at

least three clinical quality or utilization measures

2. Setting goals/acting to improve quality on at least one patient experience measure

3. Setting goals/acting to improve timeliness of patient access

4. Setting goals/acting to improve coordination with primary care

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PCSP 6C: Implement & Demonstrate Continuous Quality Improvement

The practice demonstrates ongoing monitoring of the effectiveness of its improvement process by:5. Tracking results over time6. Assessing the effect of its actions7. Achieving improved performance on one

measure8. Achieving improved performance on a

second measure 9. Setting goals and addressing at least one

identified disparity in care/service for vulnerable populations

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PCSP 6C: Implement & Demonstrate Continuous Quality Improvement

• MUST PASS• 4 Points• Scoring

– 100% - 6-9 factors– 75% - 4-5 factors– 50% - 3-4 factors– 25% - 2 factors– 0% - 0-1 factor

• Documentation– Factors 1- 9: Reports or completed PCSP Quality

Measurement and Improvement Worksheet

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PCSP 6C: Quality Measurement and Improvement Instructions

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PCSP 6C: Quality Measurement and Improvement Worksheet

Performance Measures (A) Disparities in Care (A) Patient/Family Experience (B)

Measure (C) Opportunity Identified (C) Initial Performance/ Measurement Period (A/B) Performance Goal (C) Action Taken and Date (C) Re-measurement Performance (C) Demonstrate Improvement (C)

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PCSP 6C, Factor 5: Example Tracking

Data Over Time Aug-14 Sep-14 Oct-14 Nov-14 Dec-14

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PCSP 6D: Report Performance

The practice shares performance data from Element A and Element B:1. Within the practice, results by

individual clinician 2. Within the practice, results

across the practice 3. Outside the practice to

patients or publicly, results across the practice or by clinician

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PCSP 6D: Report Performance

• 2 Points• Scoring

– 100% - 3 factors– 75% - 2 factors– 50% - 1 factor– 25% - no scoring option– 0% - 0 factors

• Documentation– Factors 1-2: Reports to practice or clinicians and

practice staff; explains how results are provided– Factor 3: Example of report to patients or the public

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PCSP 6D: Example Reporting by Clinician

1 2 3 4 5 6

Blinded 6 Clinicians

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PCSP 6D: Example Practice Level Diabetes Data

Jan-2015

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PCSP 6D: Example of External Reporting

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PCSP 6E: Use Certified EHR Technology

1.The practice uses an EHR system (or modules) that has been certified and issued a Certified HIT Products List (CHPL) Number(s) under the ONC (Office of the National Coordinator for Health Information Technology) HIT certification program

2.The practice attests to conducting a security risk analysis of its electronic health record (EHR) system (or modules) and implementing security updates as necessary and correcting identified security deficiencies+

3.The practice demonstrates capability to submit electronic syndromic surveillance data to public health agencies electronically++

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PCSP 6E: Use Certified EHR Technology (cont.)

4.The practice demonstrates capability to identify and report cancer cases to a public health central cancer registry electronically++

5.The practice demonstrates capability to identify and report specific cases to a specialized registry electronically (other than a cancer registry)++

6.The practice reports clinical quality measures to Medicare or Medicaid agency as required for Meaningful Use.

7.The practice demonstrates the capability to submit electronic data to immunization registries or immunization information systems.+

+ 2 Core Meaningful Use Requirement ++Stage 2 Menu Meaningful Use Requirement 

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PCSP 6E: Use Certified EHR Technology

• 0 Points• Documentation

– Factors 1-7: Responding “yes” or “no” in each element of the survey tool is an attestation that the practice meets the respective requirements

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Meaningful Use Attestation Accepted Attestation

Attestation Tracking InformationAttestation Confirmation Number

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NCQA Resources Available

Free training each month http://www.ncqa.org/rptraining.aspx

• Getting On Board Includes How to Submit as a Multi-

site

• Standards (2-part program)

• Software Training Using the ISS System The Online Application

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NCQA Contact InformationVisit NCQA Web Site at www.ncqa.org to:

– Follow the Start-to-Finish Pathway– View Frequently Asked Questions– View Recognition Programs Training Schedule

For questions about interpretation of standards or elements to submit a question to my.ncqa (Policy/Program Clarification Support & Recognition Programs)

Contact NCQA Customer Support at 888-275-7585 M-F, 8:30 a.m.-5:00 p.m. ET to:– Acquire standards documents, application

account, survey tools– Questions about your user ID, password,

access

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Questions?