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NCQA Standards Workshop
Physician Practice Connections - Patient-Centered Medical Home
(PPC®-PCMH™)
2009
Agenda
• Patient-Centered Medical Home Overview
• Content of PPC-PCMH
– Standards
– Documentation examples*
• Recognition Process
* Examples in the presentation only illustrate the element intent.
They are NOT definitive nor the only methods of documenting how
the elements may be met
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The Patient-Centered Medical Home Defined
ACP, AAFP, AAP, AOA Joint Principles – April 2007
• Personal physician – each patient has an ongoing relationship with a personal
physician trained to provide first contact, continuous and comprehensive care.
• Physician directed medical practice – the personal physician leads a team of
individuals at the practice level who collectively take responsibility for the
ongoing care of patients.
• Whole person orientation – the personal physician is responsible for providing
for all the patient’s health care needs or taking responsibility for appropriately
arranging care with other qualified professionals. This includes care for all stages
of life; acute care; chronic care; preventive services; and end of life care.
• Care is coordinated and/or integrated across all elements of the complex
health care system (e.g., subspecialty care, hospitals, home health agencies,
nursing homes) and the patient’s community (e.g., family, public and private
community-based services). Care is facilitated by registries, information
technology, health information exchange and other means to assure that
patients get the indicated care when and where they need and want it in a
culturally and linguistically appropriate manner.
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PPC-PCMH Content and Scoring
Standard 1: Access and Communication
Pts
Standard 5: Electronic Prescribing
Pts
A.
B.
4
5
A.
B.
C.
3
3
2
Access and communication processes**
Access and communication results**
9
Standard 2: Patient Tracking and Registry Functions
Pts
A.
B.
C.
D.
E.
F.
2
3
3
6
4
3
Basic system for managing patient data
Electronic system for clinical data
Use of electronic clinical data
Organizing clinical data**
Identifying important conditions**
Use of system for population management
21
Standard 3: Care Management
Pts
A.
B.
C.
D.
E.
3
4
3
5
5
Guidelines for important conditions **
Preventive service clinician reminders
Practice organization
Care management for important conditions
Continuity of care
20
Standard 4: Patient Self-Management Support
Pts
A.
B.
2
4
Documenting communication needs
Self-management support**
6
**Must Pass Elements
Electronic prescription writing
Prescribing decision support - safety
Prescribing decision support - efficiency
8
Standard 6: Test Tracking
Pts
A.
B.
7
6
Test tracking and follow up**
Electronic system for managing tests
13
Standard 7: Referral Tracking
Pts
A.
4
Referral tracking**
4
Standard 8: Performance Reporting and
Improvement
Pts
A.
B.
C.
D.
E.
F.
3
3
3
3
2
1
Measures of performance **
Patient experience data
Reporting to physicians **
Setting goals and taking action
Reporting standardized measures
Electronic reporting to external entities
15
Standard 9: Advanced Electronic Communications
Pts
A.
B.
C.
1
2
1
Availability of interactive website
Electronic patient identification
Electronic care management support
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PPC-PCMH Scoring
Level of
Qualifying
Points
Must Pass Elements
at 50% Performance Level
Level 3
75 - 100
10 of 10
Level 2
50 – 74
10 of 10
Level 1
25 – 49
5 of 10
Not Recognized
0 – 24
<5
Levels: If there is a difference in Level achieved between the number of points and “Must
Pass”, the practice will be awarded the lesser level; for example, if a practice has 65 points
but passes only 7 “Must Pass” Elements, the practice will achieve at Level 1.
Practices with a numeric score of 0 to 24 points or less than 5 Must Pass Elements are not
Recognized.
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PCMH Must Pass Elements
1.
PPC1A: Written standards for patient access and patient
communication
2.
PPC1B: Use of data to show meeting this standard
3.
PPC2D: Use of paper or electronic-based charting tools to organize
clinical information
4.
PPC2E: Use of data to identify important diagnoses and conditions in
practice
5.
PPC3A: Adoption and implementation of evidence-based guidelines for
three conditions
6.
PPC4B: Active support of patient self-management
7.
PPC6A: Tracking system for tests and to identify abnormal results
8.
PPC7A: Tracking referrals with paper-based or electronic system
9.
PPC8A: Measurement of clinical and/or service performance
10.
PPC8C: Performance reporting by physician or across the practice
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Data Sources & Health Information Technology
(HIT) Guidance
• Elements may have multiple suggestions for data sources and
documentation– select what your practice would use to
demonstrate that function and describe how it is used
• Each element indicates the type of health information
technology needed to perform the functions
– Basic – (HIT) Basic
• Paper-based or basic (mostly administrative) electronic system
– Intermediate – (HIT) Intermediate
• Electronic system for clinical functions
– Advanced – (HIT) Advanced
• Electronic system with connectivity or interoperability with other
systems
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PCMH Elements by Type of Information
Technology (IT)
Basic
Intermediate
Advanced
PPC 1 A - B
PPC 2 B, C, F
PPC 6 B
PPC 2 A, D, E
PPC 5 A - C
PPC 8 F
PPC 3 A - E
PPC 8 E
PPC 4 A - B
PPC 9 A - C
PPC 6 A
PPC 7 A
PPC 8 A - D
TOTAL = 18
TOTAL = 10
TOTAL = 2
Practice can achieve a passing score on Must Pass
Elements with Basic Information Technology
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PPC1 - Access and Communication
Patient access to care and communication
• PPC1A: Access and communication processes
• PPC1B: Access and communication results
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PPC 1 Element A: Access and
communication processes
Practice has written
process for*:
– Scheduling patients with
same clinician
– Coordinating visits with
multiple clinicians during
one trip
– Determining how soon a
patient needs to be seen
– Responding to urgent calls
within specified time
– Providing telephone advice
– Providing language
services
Must Pass - 4 points
• Scoring: based on 12
items
–
–
–
–
–
9-12 items = 100%
7-8 items = 75%
4-6 items = 50%
2-3 items = 25%
0-1 item = 0%
• Documentation:
–
–
–
–
Written process
Policies and procedures
Instructions
Appointment system
*Shows 6 of 12 items in Element A
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PPC1A: Scheduling Policy
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PPC 1 Element B: Access and
communication results
• Practice shows how it
meets patient access
and communication
standards
– Visits with assigned
physician
– Appointments scheduled to
accommodate patient
condition and need
– Timely response to phone,
e-mail and Internet
requests
– Language services if the
practice’s population
requires it
Must Pass - 5 points
• Scoring: Based on
number of items met of 5
–
–
–
–
–
5 items = 100%
4 items = 75%
3 items = 50%
2 items = 25%
0-1 item = 0%
• Data source:
– Reports
– Logs or screen shots
showing records of appts.
scheduled and time for
returning calls
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Access Standards with Specific Targets and Result
Measurements
Standards
Results Measurements
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PPC2 - Patient Tracking and Registry
Functions
Systematic use of patient information for
population management to support patient
care
•
•
•
•
•
•
PPC2A: Basic System for Managing Patient Care
PPC2B: Electronic System for Clinical Data
PPC2C: Use of Electronic Clinical Data
PPC2D: Organizing Clinical Data
PPC2E: Identifying Important Conditions
PPC2F: Use of System for Population Management
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PPC2A: Basic System for Managing Patient Data
Practice uses electronic
data system for searchable
patient information
1-9. Name, DOB, gender,
marital status, language
preference, race/ethnicity,
address, phone, email
10-11. Internal and external IDs
12. Emergency contact info.
13. Current and past diagnoses
14. Dates of prior visits
15. Billing code
16. Legal guardian
17. Health insurance coverage
18. Preferred method of
communication
2 points
• Scoring: Number of
items met of 18
–
–
–
–
–
12-18 items = 100%
8-11 items = 75%
6-7 items = 50%
4-5 items = 25%
0-3 items = 0%
• Data source:
– Reports from electronic
system showing data
items entered for 75100% of patients
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Element A- Report Showing Basic Patient
Information Field Use
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PPC2B: Electronic System for Clinical Data
Practice uses clinical
3 points
data systems to manage • Scoring: Number of items
care of patients has
met of 10
searchable data fields for
– 9-10 items = 100%
clinical patient
– 7-8 items = 75%
information:
– 5-6 items = 50%
1. Preventive services
2. Allergies/adverse reactions
3. Blood pressure
4-5. Height and Weight
6. BMI
7-9. Lab test, imaging and
pathology results
10. Advance directives
11. Head circumference (for
patients ≤ 2 years
– 3-4 items = 25%
– 0-2 items = 0%
• Data source:
– Reports or screen shots
showing data fields in
patient records
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Example PPC2B: Screen Shot of Data Fields
for Clinical Data
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PPC2C: Use of Electronic Clinical Data
Practice uses the
fields listed in 2B
consistently in patient
records
1. Preventive services
2. Allergies
3. Blood pressure
4-5. Height and Weight
6. BMI
7-9. Lab test, imaging and
pathology results
10. Advance directives
3 points
• Scoring: Practice enters a
percentage of patients
seen in past 3 months with
7 fields completed:
–
–
–
–
–
75-100% of patients = 100%
50-74% of patients = 75%
25 -49% of patients = 50%
10-24% of patients = 25%
<10% of patients = 0%
• Data source:
– Reports from electronic
system OR
– Record Review Workbook
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Element C: Report of percent of patients with
clinical data items entered in system
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What is the Record Review Workbook?
• Elements PPC 2C, 2D, 3D, 4B
• Require medical record abstraction of data
• Need % of patients based on numerator and
denominator
• Two methods to collect and submit patient
data
– Method #1 - report from the electronic system
– Method #2 – Record Review Workbook
• Excel workbook in the Survey Tool
• Tool to identify sample of patients and abstract data needed
for Elements 2C, 2D, 3D, 4B
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Example PPC 2C, 2D, 3D, 4B Option
NCQA Medical Record Review Worksheet
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Selecting Patients for Record Review Workbook
~Use same 36 patients for EACH Workbook Element~
STEP #3.
• Use appointment or billing system to identify
patients with visit on April 30
• Choose patients with any of three clinically
important conditions who had a visit on this date
related to the conditions
STEP #1. START
DATE = Today’s
date June 1
STEP #4. Continue choosing patients
going back on consecutive dates until
all 36 patients are selected
STEP #2. Go back
30 days = May 1
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PPC2D: Organizing Clinical Data
•
Practice uses paper or
electronic charting tools
used to organize and
document clinical
information
1.
2.
3.
4.
5.
6.
•
7.
Problem lists
Medication lists (OTC)
Medication lists (RX)
Template for risk factors
Templates for progress
notes
Screening for
developmental testing
Growth charts & BMI
Based on number of items
documented in records of
patients seen in last 3
months
Must Pass – 6 points
• Scoring - % of patients with 3
tools documented:
–
–
–
–
–
75-100% = 100%
50-74% = 75%
25-49% = 50%
10-24% = 25%
<10% = 0%
• Data source
– Record Review Workbook or
– Electronic system report with
percent of patients seen in past 3
months
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PPC 2D - what to look for in the medical record:
Documented Risk Factors And Medication Lists In
Paper Flow Sheet
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PPC2D: Pediatric Weight Chart
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PPC2E: Identifying Important Conditions
•
Practice identifies
1. Most frequently seen
diagnoses = most often
seen, single episode or
chronic; identify by number
of patients, visits, total fees
billed
2. Most important risk factors
= for the demographic
population
3. Three clinically important
conditions (chronic or
recurring) = practice
identifies
Must Pass – 4 points
• Scoring
–
–
–
–
3 items = 100%
2 items = 75%
1 item = 50%
0 items = 0%
• Data source
– Reports from EHR, practice
management system,
billing or scheduling
system for frequent Dx
– Identify risk factors in
reports
– Identify conditions and
why selected in the
Support Text/Notes
section
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PPC2E: Example Text Notes in Survey Tool
“Attached are 3 reports:
1. Frequent diagnoses: Dates of service and the
diagnosis codes, sorted by codes for frequency.
2. Risk factors: Source of Community Statistics for Risk
Factors - www.CDC.gov and
http://apps.nccd.cdc.gov/brfss/display_PF.asp
3. Clinically important conditions: As part of a National
PCMH Demonstration Project, the Demonstration
Project Stakeholders have chosen Diabetes,
Hypertension and Hyperlipidemia which represent the
best likelihood of being amenable to care
management and providing value on costs to the
health care system based on regional experience.”
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PPC2F: Use of System for Population Management
Practice uses
3 points
electronic information • Scoring: Practice takes
to generate lists of
action on
patients and remind
– 5-7 items = 100%
patients and
– 3-4 items = 75%
clinicians proactively
– 1-2 items = 50%
– 0 items = 0%
of services needed:
1.
2.
3.
4.
5.
6.
7.
Pre-visit planning
Clinician action
Specific medications
Preventive care
Specific tests
Follow-up visits
Care management
services
–
Practice gets partial credit If
system can generate lists but
practice does not use it
• Two Data sources:
1. Lists generated -- reports from
EHR, registry and
2. Example of use of the lists -screen shots, written
description of process
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Population Management Examples
EHR Query-Patients Needing
Pneunomax vaccine
Report – Patients on a Specific
Medication
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PPC3: Care Management
Practice maintains continuous relationship with patients
by using evidence-based guidelines and applying
them to needs of individual patients over time.
•
•
•
•
•
PPC3A: Guidelines for Important Conditions
PPC3B: Preventive Service Clinician Reminders
PPC3C: Practice Organization
PPC3D: Care Management for Important Conditions
PPC3E: Continuity of Care
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PPC3A: Guidelines for Important Conditions
• Practice adopts and
implements
evidence-based
diagnosis and
treatment guidelines
for three clinically
important conditions
• Use same conditions
in PPC2D, 2E, 3A, 3D,
4B, 9C
Must Pass – 3 points
• Scoring
–
–
–
–
3 conditions = 100%
2 conditions = 50%
1 condition = 25%
0 conditions = 0%
• Data source: workflow
organizers that show
guidelines adopted and
implemented
– Provide source of guidelines
– Paper flow sheets, templates for
documenting progress
– Screen shots showing templates
for treatment plans and
documenting progress
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Example PPC3A – Adoption of
Evidence –Based Diagnosis and Treatment Guidelines
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Example – Evidence-Based Diabetic Workflow Organizer
(shows what to document at each visit)
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Example PPC3A - EHR Prompting Lipid Management
Evidence-Based Guidelines
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PPC3B: Preventive Service Clinician Reminders
• Practice generates
reminders about
preventive services
for clinicians
• Practice uses paper
or electronic
guideline-based
alerts and reminders
to write orders and
conduct
assessments
1.
2.
3.
4.
Screening tests
Immunizations
Risk assessments
Counseling
4 points
• Scoring
–
–
–
–
–
Reminders for 4 items = 100%
Reminders for 3 items = 75%
Reminders for 2 items = 50%
Reminders for 1item = 25%
Reminders for no items = 0%
• Data source: reports, screen
shots, templates or paper flow
sheets showing decisionsupport for clinicians during
visits, calls and email.
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Example PPC3B - Preventive Service
Reminders for Clinicians
Paper Reminder for Risk
Assessments, Immunizations,
Screening Tests
EHR with Risk Assessment
Reminders
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PPC3C: Practice Organization
•
Care team manages patient
care:
1. Non-physician staff remind
patients of appointments and
collect information before
appointments
2. Non-physician staff execute
standing orders (e.g. med.
refills, order tests)
3. Non-physician staff educate
patients to manage conditions
4. Non-physician staff coordinate
care with external disease
management or case
management organizations
3 points
• Scoring
–
–
–
–
4 items = 100%
3 items = 75%
2 items = 50%
0-1 item = 0%
• Data source
– Job descriptions
– Protocols
– Written standing
orders
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Example PPC3C: Practice Organization Standing Orders
Note: If patient needs OV or labs, refill up to one month (one time only).
If more requested, check with physician
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PPC3D: Care Management for Important Conditions
To manage care of patients with three
clinically important conditions, practice
uses:
1.
Pre-visit planning
2.
Individualized written care plans
3.
Individualized treatment goals
4.
Assess progress toward goal
5.
Review of medications with patients
6.
Review self-monitoring results and
include in medical record
7.
Assess barriers when patient not met
treatment goals
8.
Assess barriers when patient not filled
prescriptions or took meds.
9.
Follow-up when patient not kept
important appointments
5 points
• Scoring – patients seen in
past 3 months have 4
items documented:
–
–
–
–
–
≥75% of patients = 100%
50-74% of patients = 75%
25-49% of patients = 50%
11-24% of patients = 25%
≤10% of patients = 0%
• Data source
– Report from electronic
system showing percent
of patients seen with
documentation of items
OR
– Record Review Workbook
10. Review patient clinical data over time
11. After-visit follow-up
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PPC3D: Written Care Plan in Medical Record
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PPC 3D - what to look for in the medical record:
Documented Patient Progress and Treatment Goals
Patient Progress, Treatment
Goals and Medication Review
Patient Progress and Treatment Goals
Medication Review
Patient progress
Assessment & Plan
Treatment plan and goals
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PPC3E: Continuity of Care
Practice provides continuity of care for
patients who receive care in inpatient
or outpatient facilities
1. Identifies patients
2. Sends information to facilities and
patients
3. Reviews information from facilities to
identify patients needing proactive
contact or are at risk for adverse
outcomes
4. Contacts patients post-discharge
5. Provides or coordinates follow-up care
to discharged patients
6. Coordinates care with external disease
or care management organizations
7. Communicates with patients getting
disease or high risk case management
8. Communicates with case managers for
patients getting disease or high risk
case management
9. Develops written transition plan with
patient for transition to other care
10. Coordinates with new physicians
5 points
• Scoring
–
–
–
–
5-10 items = 100%
3-4 items = 75%
2 items = 50%
0-1 item = 0%
• Data source: from practice
or external organization
– Protocols re: timeline for
patient follow-up
– Protocols for care plans
– Log of patients receiving
care from other facilities
– Registry, EHR, hospital or ER
reports
– Health needs assessments
– Blinded case management
or medical record notes
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Example – ER Visit Follow-Up Log
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Example – Follow-Up Care after Hospital
Admission
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PPC4 - Patient Self-Management
Support
Improve patient ability for
self-management by:
• PPC 4A - Documenting communication
needs
• PPC 4B - Providing self-management
support
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PPC4A: Documenting Communication Needs
Practice assesses
2 Points
patient-specific
• Scoring:
barriers to
– 2 items = 100%
communication using
systematic process
– 1 item = 50%
to:
– 0 items = 0%
1. Identify and display in
• Data source - How practice
record patient
language preference
– Records language preference:
screen shots, patient
2. Assess both hearing
assessment forms
and vision barriers
– Determines % of patients
preferring another language:
reports from EHR, patient
record review
Physician Practice Connections─Patient-Centered Medical Home
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PPC4A: Example Documenting
Communication Needs
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PPC4B: Self-Management Support
•
Must Pass – 4 points
Practice documents
patient self-management • Scoring – % of patients seen in
past 3 months have 3 items
support for 3 clinically
documented:
important conditions
1.
Assess patient preferences,
readiness and ability for selfmanagement
2. Provides educational
resources in patient language
3. Provides self-monitoring tools
for patients
4-6. Provides or connects patient
with support programs,
classes, resources
7. Provides patient with written
care plan
–
–
–
–
–
75-100% patients = 100%
50-74% = 75%
25-49% = 50%
11-24% = 25%
≤10% = 0%
• Data source
– Record Review Workbook or
– Report from electronic system
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PPC 4B - what to look for in the medical record:
Documented Use of Self-Monitoring Tools & Program
Referrals
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PPC5: Electronic Prescribing
Practices uses electronic systems to order
prescriptions, to check for safety and to
promote efficiency when prescribing.
• PPC5A: Electronic Prescription Writing
• PPC5B: Prescribing Decision Support –
Safety
• PPC5C: Prescribing Decision Support –
Efficiency
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PPC5A: Electronic Prescription Writing
Practice uses an
electronic system to
write prescriptions
1.
2.
Stand-alone system (i.e.,
hand-held e-prescribing
device, PDA)
System that links data to
specific patients (i.e., EHR)
3 points
• Scoring
– 75-100% of prescriptions for
patients seen in past 3 months
written with item 2 = 100%
– 75-100% of prescriptions for
patients seen in past 3 months
written with item 1 = 75%
– System capable of either item 1
or 2 but practice does not use or
cannot report %= 25%
– No system capability or <75% of
item 1 or 2 = 0%
• Data source:
– Reports showing practice used
system for writing prescriptions
for 75-100% of patients within
past 3 months
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PPC5A: Example Prescribing Method
EXPLANATION
 January to March 2009 prescribing method is documented in the table.
 Certain prescriptions (Schedule II) must be printed on special paper
prescription pads in our state.
 96% of prescriptions were generated from our electronic medical record.
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Example PPC 5A - % of Use for Electronic Prescriptions
Evaluation:
Our Physicians and nurses put all prescriptions in our EMR which is linked to
patient -specific demographic and clinical data.
Note the screen shot that denotes the number of scripts for our physicians in
the last three months, 2046 and the report which notes the number of
patients seen during that same time period, 2482.
We propose that this represents a percentage between 75% and 100%,
understanding that one prescription does not mean one patient.
2046 prescriptions provides the numerator to determine the percentage. The
practice provided another report showing the summary of the 2482 patients
seen during the same period to provide the denominator
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PPC5B: Prescribing Decision Support – Safety
Electronic prescription
reference information at the
point of care including alerts
and information:
1-2. drug-drug interactions -
general and patient-specific
3-4. drug-disease interactions –
general and patient-specific
5-6. Drug-allergy alerts - general
and patient-specific
7. Drug-patient history alerts
8-9. Appropriate dosing – general
and patient specific
10. Drug-lab alerts – general
11-12. Duplication of drugs –
general and patient-specific
13-14. Drugs to be avoided in
elderly
15. Patient-appropriate
medication information
3 points
• Scoring
– Practice uses ≥8 alerts and
information = 100%
– Practice uses 4-7 alerts and
information = 75%
– Practice uses 2-3 alerts = 50%
– System has >6 alerts but not
used = 25%
– No system capability or <6
alerts or practice uses <2
alerts
• Data source:
– Reports from system, showing
example of each item
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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Example PPC5B - EHR Prescription
Allergy Pop Up Box (safety check)
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PPC5C: Prescribing Decision Support – Efficiency
Cost-efficient
electronic
prescription writer
with:
1. Automatic alerts for
drug choices,
including generics
2. Payer-specific
formulary that alerts
clinician to alternative
drugs, including
generics
2 points
• Scoring
– Practice uses 2 tools = 100%
– Practice uses 1 tool = 75%
– System has both tools but
practice doesn’t use it = 25%
– System lacks capability or
practice does not use either
tool = 0%
• Data source
– Reports
– Screen shots
– Practice protocols
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PPC5C: Prescribing Decision Support – Efficiency
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PPC6 - Test Tracking
Practice systematically tracks tests ordered
and test results, and systematically follows
up with patients.
• PPC 6A - Test tracking and follow-up
• Basic – if paper system
• Intermediate – if electronic communication within the
practice office
• Advanced – if electronic communication between
practice and lab and imaging facilities
• PPC 6B - Electronic system for managing tests
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PPC6A: Test Tracking and Follow-up
Practice uses paper or
electronic system to track
tests and follow up
1. Tracks lab tests until results
return to practice and flag
overdue results
2. Tracks imaging tests until
results return to practice and
flag overdue results
3. Flag abnormal test results
4. Notify patients of abnormal
results
5. Follows up with inpatient
facility on hearing and
metabolic screening
6. Notifies patients of normal
results
Must Pass – 7 points
• Scoring
– 4-6 items = 100%
– 3 items = 50%
– System can do 4 types of
tracking but isn’t in use = 25%
– System can’t track or practice
uses <3 types of tracking and
follow-up = 0%
• Data source:
– Evidence that practice reviews
and uses tracking log before or
at beginning of patient visits
– Reports or tracking logs or email inbox flagging results
• Filing results in the medical
record until patient comes in
does not meet tracking and
follow-up standard
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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Example PPC6A - Lab Tracking
Manual Log
Spreadsheet
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PPC6A: Example Notifies Patient of Abnormal
Results
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PPC6B: Electronic System for Managing Tests
•
Electronic system to
1-2. Order lab and imaging tests
3. Retrieve results from source
4-5.Retrieve imaging text and
images from source
6. Route and manage current
and historical test results to
appropriate personnel for
review
7. Flag duplicate tests
8. Generate alerts for
appropriateness
•
Assumes electronic
communication between
practice and lab and
imaging facilities
6 points
• Scoring
–
–
–
–
5-8 functions = 100%
3-4 functions = 75%
1- 2 functions = 50%
Doesn’t use system = 0%
• Data source
– Reports or screen shots
showing examples of required
functions
– Filing results in the medical
record until patient comes in
does not suffice for tracking
and follow-up
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
63
Example PPC6B - EHR Order Screens
Laboratory Test Order Screen
Radiology Test Order Screen
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PPC7 - Referral Tracking
PPC 7A - Document and track referrals
and referral results
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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Example PPC7A - Manual Consultant
Tracking Logs
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PPC7A: Example Referral Results
REFERRAL RESULTS
 Caregiver
 Patient
 Dates
 Status (Reviewed)
 Type (Referrals)
 Patient/Procedure
 Date Ordered
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PPC8: Performance Reporting
and Improvement
Practice regularly measures its performance and
takes actions to continuously improve
• PPC8A: Measures of Performance
• PPC8B: Patient Experience Data
• PPC8C: Reporting to Physicians
• PPC8D: Setting Goals and Taking Action
• PPC8E: Reporting Standardized Measures
• PPC8F: Electronic Reporting ─ External Entities
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PPC8A: Measures of Performance
•
•
•
Practice measures or
Must Pass – 3 points
receives clinical and/or
service performance
• Scoring – performance
data
measurement:
1.
2.
3.
4.
Clinical process
Clinical outcomes
Service data
Patient safety issues
Reports may be
generated by the
practice, an affiliated
medical group or
health plan
Credit given for NCQA
Recognition for items 1
and 2
– 2 types = 100%
– 1 type = 50%
– No measures = 0%
• Data source - Reports from
– Manual review of sample of
patient records
– Patient surveys
– Practice management
system
– Registry
– Data from health plan or
larger medical group
– Electronic database
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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NCQA Clinical Program Recognition
Where Can it Be Used to Meet Element?
• NCQA Clinical Recognition Programs
– Diabetes Recognition Program (DRP)
– Heart/Stroke Recognition Program (HSRP)
– Back Pain Recognition Program (BPRP)
• Credit for Clinical Program Recognition may be
used for meeting requirements in 7 elements
if majority of physicians are Recognized:
– PPC 3A, 3D (for selected conditions used for survey)
– PPC 8A, 8C, 8D, 8E, 8F
Physician Practice Connections─Patient-Centered Medical Home
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Example PPC8A – Plan and Network Level Reports
CAHP’s Patient Satisfaction Report
Clinical Performance Report
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PPC8B: Patient Experience Data
Practice collects data
on patient experience
with are:
1. Patient access to care
2. Quality of physician
communication
3. Patient confidence in selfcare
4. Patient satisfaction with
care
3 points
• Scoring – practice
collects data on
– 3-4 areas = 100%
– 1-2 areas = 50%
– 0 areas = 0%
• Data source:
– Reports of paper,
telephone, or electronic
survey
– Practice must provide
summarized data, not a
blank survey
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PPC8B: Patient Experience Data
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PPC8C: Reporting to Physicians
Practice reports
performance on
measures in PPC8A
1. Across the practice
2. By individual physician
Must Pass – 3 points
• Scoring - practice reports:
– Across practice and by
physician = 100%
– Either across practice or by
physician = 50%
– No reporting = 0%
• Data source:
– Blinded reports with
performance data
– Blinded letters to physicians
with performance data
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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Example of B – Reporting Across the Practice
and Across Multiple Practice Sites
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PPC8D: Setting Goals and Taking Action
Practice uses
performance data to
1. Set goals based on
performance data in
PPC8A and 8B
2. Takes action to
improve performance
of individual
physicians or
practice
3 points
• Scoring
– 2 items = 100%
– 1 items = 50%
– 0 items = 0%
• Data source:
– Practice-specific
reports or
– Completion of NCQA’s
Quality Improvement
Workbook
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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Example PPC8D – NCQA’s QI Worksheet
Documenting Setting Goals And Taking Action
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PPC8E: Reporting Standardized Measures
Practice produces reports
on performance using
nationally approved
clinical performance
measures
– National Quality Forum
endorsed physician level
measures
2 points
• Scoring based on
number of measures the
practice reports
–
–
–
–
≥10 items = 100%
5-9 items = 75%
3-4 items = 50%
0-2 items = 0%
• Data source:
– Reports showing
performance measures
calculated by practice
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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Example PPC8E - National Quality Forum Endorsed
Physician Level Measures
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PP8F: Electronic ReportingExternal Entities
• Practice electronically
reports results on
nationally approved
measures to external
entities
• Practice gets partial
credit if its system has
the capability to report
data but does not use
it
1 point
• Scoring based on number
of measures practice
reports
–
–
–
–
–
≥10 measure = 100%
5-9 measures = 75%
3-4 measures = 50%
1-2 measures = 25%
0 measures = 0%
• Data source:
– Report to public sector, health
plans or others
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PP8F: Example Electronic ReportingExternal Entities
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PPC9: Advanced Electronic
Communication
Practice uses electronic communication to
improve timeliness, effectiveness,
efficiency and coordination of care.
• PPC9A: Availability of Interactive Web
Site
• PPC9B: Electronic Patient Identification
• PPC9C: Electronic Care Management
Support
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PPC9A: Availability of Interactive Web Site
Patient has access
to Interactive Web
site to:
1. Request
appointments
2. Request referrals
3. Request test results
4. Prescription refills
5. See medical record
6. Import medical data
to personal records
1 point
• Scoring – practice
provides
–
–
–
–
5-6 items = 100%
3-4 items = 75%
1-2 items = 50%
0 items = 0%
• Data Source: screen
shots showing Web
functionality
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PPC9A: Example Interactive Website
Factor 2, Requesting Appointment
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PPC9B: Electronic Patient Identification
Electronic information
and clinical decisionsupport to contact
patients by email
needing:
1. Clinical review or action
2. On a particular
medication
3. Preventive care
4. Special tests
5. Follow-up visits
6. Disease/case
management support
2 points
• Scoring
–
–
–
–
5-6 items = 100%
3-4 items = 75%
1-2 items = 50%
0-1 items = 0%
• Data source
– Screen shots showing
identification of patients
and example of e-mail
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PPC9B: Example Electronically Contacting
Patient to Review Test Results
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PPC9C: Electronic Care Management Support
Electronic care
management support for
three clinically important
conditions to
1. Communicate with
disease/care managers
about patient needs
2. Provide Web-based
educational modules for
patient self-management
1 point
• Scoring
–
–
–
–
4 items = 100%
3 items = 50%
2 items = 25%
0-1 items = 0%
• Data source
– Screen shots showing
electronic communication
about care management
– Screen shots or links to
educational modules
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PPC 9C: Example Electronic Care
Management Support
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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Example PPC 9C: Diabetes Education
Web-sites for Patient Self-Management
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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What is the PPC-PCMH application
and survey process?
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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Recognition Process
• Practices may use the Survey Tool to self-assess
before submitting to NCQA
• Recognition is based on:
– Responses in Web-based Survey Tool
– Supporting documentation attached to Survey Tool
• Element specifies type of documentation
– Reports
• Reports from EHR, registry, practice management & billing
systems
– Documentation of processes
• Policies and procedures, protocols
– Records or files
• NCQA’s Medical Record Review Workbook
• Screen shots from EHR
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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Who is Recognized?
• NCQA Recognizes practices that meet
the criteria described by the endorsed
principles of the Patient-Centered
Medical Home
• NCQA defines a practice as a physician
or physicians practicing together at a
single geographic location
• Recognition is at the practice-site level
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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NCQA’s
Interactive Survey System (ISS)
• ISS is a Web-based application program
• The practice uses ISS (Survey Tool) for:
– Entering responses to each factor for
each element
– Attaching documents and providing
text to support the responses
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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Steps for the Physician/Practice
1.
Review program information
2.
Participate in a standards workshop (See
www.ncqa.org/rptraining.aspx)
3.
Obtain a Survey Tool
4.
Participate in a WebEx ISS demonstration of the
Survey Tool
5.
Use Survey Tool to self-assess current performance
6.
Submit completed application, agreements, fee,
and results to NCQA when ready
7.
Receive final Recognition decision and Level in 30 –
60 days
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PPC-PCMH Survey Process
1.
2.
NCQA receives Survey Tool
NCQA evaluates Survey Tool
•
•
3.
4.
5.
On-site audit - 5% of practices
Final decision and status determined
Report results with Level 1, 2, or 3
•
•
6.
7.
Responses, documentation, and explanations
Practice may be contacted for clarifications
Recognition posted on NCQA Web site
Not passed - not reported
PPC-PCMH certificate and recognition packet
Practice achieving Level 1 or 2 can do add-on
survey within the 3 year recognition time period
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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Results: Impact of Program
• Better chronic-care management programs
• Greater attention to patient compliance
• Improved patient outreach
– Patient reminders, increased screenings
– Educational materials
• Increased data collection and reporting
• Significant adoption and use of patient registries
Measurement + Rewards = Improvement!
Physician Practice Connections─Patient-Centered Medical Home
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NCQA Contact Information
Contact NCQA Customer Support to:
• Acquire standards documents, application materials,
and survey tools
• Questions about your user ID, password, access
• 1-888-275-7585
Visit NCQA Web Site to:
• View Frequently Asked Questions
• View Recognition Programs Training Schedule
Submit to questions to [email protected]
Please use this e-mail box to:
• Ask about interpretation of standards or elements
• Submit application materials (physician workbook and application)
• Request registration for ISS Survey Tool demonstration (Web-ex)
Physician Practice Connections─Patient-Centered Medical Home
Standards Workshop 2009
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PPC-PCMH Program Sponsors
Physician Practice Connections─Patient-Centered Medical Home
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