Transcript How to Obtain NCQA Recognition as A Patient Centered

How to Obtain NCQA Recognition
as A Patient Centered Medical
Home
Donald T. Stewart, MD
Sammamish Diabetes and Lipid Clinic
[email protected]
My Patient Centered Medical Home:
Sammamish Diabetes and Lipid Clinic
in Sammamish Washington
View from the Street, via Google
Patient Entrance
Overview
•
•
•
•
•
•
Historical Considerations
Why Does a PCMH make sense?
Who are the Players?
Who is the NCQA?
Why become NCQA Recognized
Details and steps necessary to meet NCQA
Recognition as a Patient Centered Medical
Home
Historical Considerations
• “Medical Home” first used by American Academy
of Pediatrics 1967 describing comprehensive
services for developmentally disabled patients.
• WHO Alma Alt Conference 1978 described the
Medical Home concept with Primary Care as the
centerpiece.
• Institute of Medicine 1990s
• AAFP 2002 Future of Family Medicine Project
• Joint Statement by AAFP, AAP, ACP, AOA
Joint Principles of the Medical
Home
(AAFP, ACP, AAP, AOA)
•
•
•
•
•
•
•
Personal Physician
Physician Directed Medical Practice
Whole Person Orientation
Care is Coordinated and Integrated
Quality and Safety are Hallmarks
Access is Enhanced
Payment Reform
Why Does a PCMH Make Sense?
• Although the US ranks #1 in the world in
spending, technology, and research, we rank
very poorly in outcomes, access, and fairness.
• Lack of a robust primary care work force in the
US is arguably the reason for this:
– 30% primary care, 70% specialty care in US
– 70% primary care, 30% specialty care elsewhere
– Compared to other countries, US primary care is
grossly underfunded, which keeps students from
choosing it as a career.
Why Does a PCMH Make Sense?
• The simple and obvious solution to the
problem would be to adequately fund and
support primary care in the US
• Political forces keep us from doing this:
– Insurance companies want their cut
– Specialists (the majority of MDs) want their cut
– Hospitals, Equipment Manufacturers, Technology
Firms, and Pharma all want their cut
Why Does a PCMH Make Sense?
• Given the political climate, a “gimmick” is
necessary to adequately fund primary care.
• The PCMH is that gimmick
– Our system of fragmented and impersonal care
makes the words “Patient Centered Medical
Home” resonate
– The phrase “Patient Centered Medical Home”
makes primary care seem more desirable
– And, it makes primary care seem more valuable,
thus worthy of funding
Who are the Players?
Buyers
Payors
Providers
Business
Insurance Companies
Physicians
Medicare
Medicare Intermediaries
Hospitals
Medicaid
State Medicaid
Organizations
Nursing Homes
Home Health
Providers
Patient Centered Primary Care
Collaborative (PCPCC)
1.
2.
3.
4.
Employers - 50 Million Plus
Consumer Groups - 47 Million Plus
Physician Groups - 330,000 Plus
Insurers – All of the Big Six
AARP
Aetna*
American Academy of Family Physicians*
American Academy of Pediatrics*
American Board of Medical Specialties
American College of Osteopathic Family Physicians
American Board of Medical Specialties
American College of Cardiology
American College of Osteopathic Internists
American College of Physicians*
American Geriatrics Society
American Health Quality Association
American Heart Association
American Osteopathic Association*
Aurum Dx
Automotive Industry Action Group
BlueCross BlueShield Association*
Bridges To Excellence
The Capital District Physicians’ Health
Plan, Inc.
Carena, Inc.
Caterpillar
The Center for Excellence in Primary Care
The Center for Health Value Innovation
Colorado Center for Chronic Care Innovations
CIGNA*
CVS Caremark*
§ CVS/pharmacy
§ Caremark Pharmacy Services
§ MinuteClinic
Delmarva Foundation
The Department for Family and Community Medicine, University of
California, San Francisco
Delphi Corporation
Deseret Mutual
DMAA: The Care Continuum Alliance
eHealth Initiative
The ERISA Industry Committee*
Exelon Corp
FedEx Corporation
Foundation for Informed Medical Decision Making
General Mills, Inc.
General Motors
Geisinger Health Systems
GlaxoSmithKline
Health Dialog
HR Policy Association
Humana, Inc.*
IBM*
Incenter Strategies
McKesson Corporation
MDdatacore
Medco*
Medical Network One
Merck*
MVP Health Care
National Association of Community Health Centers
National Business Group on Health
National Business Coalition on Health
National Coalition on Health Care
National Committee for Quality Assurance
National Consumers League
National Partnership for Women & Families
National Retail Federation
New England Quality Care Alliance
New York City Department of Health and Mental Hygiene
Novo Nordisk
The Pacific Business Group on Health
Partners In Care
Pfizer*
Practice Transformation Institute
Pudget Sound Health Alliance
The Roger C. Lipitz Center for Integrated Health Care at the Johns Hopkins
Bloomberg School of Public Health
Service Employees International Union
Society of General Internal Medicine
Society of Teachers of Family Medicine
The Stoeckle Center at Massachusetts General Hospital
UnitedHealthcare*
United States Steel
University of Pittsburgh Medical Center
Walgreens Health Initiatives*
WellPoint, Inc.*
Wyeth
Xerox
Updated 12/18/07
What is the NCQA?
• Private not-for-profit, formed in 1990,
dedicated to improving health care quality in
the United States
• 2007 Revenue $27,728,329.00
• Leadership Team – 10 individuals
– 1 MD
– 2 RN
– 7 others with a variety of credentials
NCQA Board of Directors
• 16 people (many from dual categories)
– 5 MDs
– 2 Attorneys
– 2 Insurance
– 3 Academics
– 3 Business
– 3 Special Interest Groups
– Consultants / Misc.
NCQA Sponsors
– Foundation Sponsors:
•
•
•
•
American Diabetes Association
American Heart Association/American Stroke Association
The California Endowment
The Commonwealth Fund
– Corporate Sponsors:
• Platinum: $250,000 and more (Pharma)
• Gold: $150,000 -$249,999 (Pharma and Partnership for
Prevention)
• Silver: $50,000 - $149,999 (Pharma)
• Bronze up to $49,999 (30 some other organizations)
NCQA Programs
• Accreditation
–
–
–
–
Health Plans
Managed Care Organizations
PPOs
Disease Management
• Certification
– Physician Organizations
– Health Information Products
– Credentials Verification Organizations
• Physician Recognition
–
–
–
–
Back Pain
Diabetes
Heart Disease and Stroke
PPC - PCMH
• HEDIS (Healthcare Effectiveness Data and Information Set)
– Yearly dataset revision
Why Become NCQA Recognized?
• The pillars of high-quality primary care are
simple:
– Access
– Efficiency
– Continuity
– Good information
– Coordination
• These are too easily assessed and measured
to qualify as the “gimmick” necessary in our
political climate to fund primary care
Why Become NCQA Recognized?
• Large organizations, top-heavy with administration,
that most people would never consider to be
“Medical Homes,” need some way to justify their
existence, and to appear to provide quality care
• Small practices, who have been practicing patientcentered care for decades, need to be “rebranded”
to qualify for adequate funding
• The dilemma is that it will be much easier for large,
impersonal organizations to become recognized as
medical homes by NCQA criteria than small, personal
practices that excel in the pillars of quality care
• Unfortunately, there is no evidence that doing many
of the things NCQA requires actually benefits anyone
Details and Steps Necessary to
Meet NCQA Recognition
as a Patient Centered Medical Home
NCQA Medical Home – Musts
• Has written standards for patient access and patient communication;
• Uses data to show it meets its standards for patient access and
communications;
• Uses paper or electronic charting tools to organize clinical
information;
• Uses data to identify important diagnoses and conditions in practice;
• Implements evidence-based guidelines for al least three conditions;
• Actively supports patient self-management;
• Tracks tests and identified abnormal results systematically;
• Tracks referrals using a paper-based or electronic system;
• Measures clinical or service performance by physician or across the
practice;
• Reports performance by physician or across the practice.
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 do
not Qualify.
Steps to NCQA Recognition
1. Download Application packet (and study it)
a)
b)
c)
d)
Dense 84 page Standards and Guidelines PDF
21 page agreement and attestation PDF
3 more documents totaling 11 pages
Two Excel Spreadsheets to fill out
2. Download Survey Tool ($80.00)
3. Gather data from your practice to support
criteria
4. Upload documentation to NCQA
5. Send in application and fee ($450.00)
The Details
(wherein the devil resides)
Standard 1 – Access and
Communication Processes
• 1 A: The practice establishes policies in
writing to support patient access (Must Pass):
1. Scheduling each patient with a personal clinician for continuity of care
2. Coordinating visits with multiple clinicians and/or diagnostic tests
during one trip
3. Determining through triage how soon a patient needs to be seen
4. Maintaining the capacity to schedule patients the same day they call
5. Scheduling same-day appointments based on practice’s triage of
patients’ conditions
6. Scheduling same-day appointments based on patient’s/family’s
request
Standard 1 – Access and
Communication Processes
• 1 A: Policies in writing (continued-Must Pass)
7.
Providing telephone advice on clinical issues during office hours by
physician, nurse or other clinician within a specified time
8. Providing urgent phone response within a specified time, with
clinician support available 24 hours a day, 7 days a week
9. Providing secure e-mail consultations with the physician or other
clinician on clinical issues, answering within a specified time
10. Providing an interactive practice Web site
11. Making language services available for patients with limited English
proficiency
12. Identifying health insurance resources for patients or families who
do not have insurance
Documenting 1A
• Sending NCQA your written policies
• Scoring 1A: the number of policies you
produce (4 points possible)
– 100%:
– 75%:
– 50%:
– 25%:
written policies for 9 – 12 items
written policies for 7 – 8 items
written policies for 4 – 6 items
written policies for 2 – 3 items
1 A: Examples of Policies
1. Patients schedule themselves online 24/7, and continuity of care is
guaranteed because there is only one provider
2. Dr. Stewart provides all patient care and does all diagnostic tests at the
office, so care is coordinated at all times
3. Patients who are unable to determine when they need to be seen can
call Dr. Stewart on his cell phone for help with triage.
4. The practice will never allow more than 6 hours a day to be
prescheduled, allowing 18 hours of capacity each day for same day
appointments
5. If the patient needs triage to determine that a same day appointment
is appropriate, the same-day appointment will be granted
6. If patient’s/family’s would prefer to request a same-day appointment,
rather than simply schedule it, they will be allowed to request it.
1 A: Examples of Policies (cont.)
7.
Dr. Stewart will provide telephone advice on clinical issues within 6
hours of the call.
8. All patients have direct access to Dr. Stewart via his cell phone 24
hours a day, 7 days a week
9. Dr. Stewart will answer e-mail consultations on clinical issues within
48 hours.
10. All patients are encouraged to use our interactive practice Web site
for scheduling, review of lab results, and secure communications
11. Although the practice is closed and none of our current patients
have limited English proficiency, if the practice ever opens up to new
patients, those with limited English proficiency will be provided
appropriate language services
12. The practice routinely provides packets of health insurance
resources for patients or families who do not have an insurance that
we accept
1B: The practice’s data shows that it meets
access and communication standards in 1A
(Must Pass):
1. Visits with assigned personal clinician for each patient
2. Appointments scheduled to meet the standards in 1A
3. Response times to meet standards for timely response to
telephone requests
4. Response times to meet standards for timely response to email and interactive Web requests
5. Language services for patients with limited English
proficiency
Documenting 1B
• Reports, screen shots, hand tracking forms.
This response times are one of the most
difficult things to document for a small
practice.
• Scoring 1B: number of items supported by
data (5 points possible)
– 100%:
– 75%:
– 50%:
– 25%:
Data supports 5 items
Data supports 4 items
Data supports 3 items
Data supports 2 items
Standard 2 – Patient Tracking and Registry
Functions
• 2A: The practice uses a data system for
patients that includes the following searchable
patient information:
1. Name
2. Date of birth
3. Gender
4. Marital status
5. Language preference
6. Voluntarily self-identified race/ethnicity
7. Address
8. Telephone (primary contact number)
9. E-mail address (or “none” for patient)
Standard 2 – Patient Tracking and
Registry Functions
• 2A: Searchable information (cont.)
10. Internal ID
11. External ID
12. Emergency contact information
13. Current and past diagnoses
14. Dates of previous clinical visits
15. Billing codes for services
16. Legal guardian
17. Health insurance coverage
18. Patient/family preferred method of communication
Problems with 2A
• Requirements far beyond CCHIT EMR
requirements:
– I had to add numerous data fields to my CCHIT
approved EMR
• Requirements make no clinical sense:
– Why would anyone want to do a search on the
name of an emergency contact or the legal
guardian of a patient?
Documentation of 2A
• A report must be generated to show how
many of the 18 data elements have been
completed for 75% or more of the patients
seen in the previous 3 months.
• Scoring: (2 points possible)
– 100%
– 75%
– 50%
– 25%
12 – 18 items documented for 75%
8 – 11 items documented for 75%
6 – 7 items documented for 75%
4 – 5 items documented for 75%
McKesson Practice Partner EMR
Custom Data Loading Screen for NCQA Data
NCQA Data in a Clinical Element Table
2B: The practice’s clinical data system or
systems to manage care of patients include the
following clinical patient information in
searchable data fields:
1.
Status of age-appropriate preventive services (immunizations,
screenings, counseling)
2. Allergies and adverse reactions
3. Blood pressure
4. Height
5. Weight
6. Body mass index (BMI) calculated
7. Laboratory test results
8. Presence of imaging results
9. Presence of pathology reports
10. Presence of advance directives
11. Head circumference for patients 2 years or younger
2C: The practice uses the fields listed in 2B
consistently in patient records.
• Calculate the percentage of patients seen in
the past three months that have at least seven
of the eleven fields from 2B completed in their
electronic record.
• Scoring: (3 points possible)
– 100%:
– 75%:
– 50%:
– 25%:
75%-100% have at least seven fields
50%-74% have at least seven fields
25%-49% have at least seven fields
10%-24% have at least seven fields
2D: The practice uses the following electronic
or paper-based charting tools to organize and
document clinical information in the medical
record (Must Pass):
1. Problem lists
2. Lists of over-the-counter medications, supplements and
alternative therapies
3. Lists of prescribed medications, including both long-term
and short-term medications
4. Structured template for age-appropriate risk factors (at
least 3)
5. Structured templates for narrative progress notes
6. Age-appropriate standardized screening tool for
developmental testing
7. Growth charts plotting height, weight, head
circumference and BMI, if less than 18 years
Documentation of 2D
• Will probably have to be done by hand chart
audits, since the items requested are not
reportable or countable by any known EMR
• Scoring: % of patients with at least 3 of the 7
items in 2D reported in last 90 days (6 points
possible)
– 100%:
– 75%:
– 50%:
– 25%:
75%-100% of patients have 3 of 2D items
50%-75% of patients have 3 of 2D items
25%-49% of patients have 3 of 2D items
10%-24% of patients have 3 of 2D items
Chart Summary in Practice Partner
2E: The practice uses an electronic or
paper-based system to identify the
following diagnoses and conditions
(Must Pass):
1. Practice’s most frequently seen diagnoses
2. Most important risk factors in the practice’s
patient population
3. Three conditions that are clinically important
in the practice’s patient population
Documenting 2E
• Diagnoses report from EMR or billing software
• Risk Factors could be things like obesity,
smoking, blood pressure, age, alcohol use
reported from EMR or chart audit
• Three conditions that are clinically important
for the practice population - this is a matter of
judgment, but Diagnosis and Risk Factors can
help lead to the decision.
Scoring 3E
• Based on number of items identified (4 points
possible)
– 100%: 3 items identified
– 75%: 2 items identified
– 50%: 1 item identified
2F: Population Management is supported
by generating lists of patients to
proactively contact for needed services:
1. Patients needing pre-visit planning (obtaining tests
prior to visit, etc.)
2. Patients needing clinician review or action
3. Patients on a particular medication
4. Patients needing reminders for preventive care
5. Patients needing reminders for specific tests
6. Patients needing reminders for follow-up visits,
such as for a chronic condition
7. Patients who might benefit from care management
support
Documenting 2F
• Screen shots, generated reports, sample recall
letters, protocols for phone or email recall,
and written description of how and when
these are used
• Scoring: how many items routinely addressed
(3 points possible)
– 100%: 5 – 7 items from 2F
– 75%: 3 – 4 items from 2F
– 50%: 1 – 2 items from 2F
7/17/2015
Sammamish Diabetes and Lipid Clinic, PLLC
52
7/17/2015
Sammamish Diabetes and Lipid Clinic, PLLC
53
Standard 3: Systematic Care
Management
• 3A: The practice adopts and implements
evidence-based diagnosis and treatment
guidelines for (Must Pass):
1. First clinically important condition
2. Second clinically important condition
3. Third clinically important condition
Documenting 3A
• Evidence based guidelines need to be
identified for the conditions in question and
proof of their use (flow charts, templates,
registry reports) has to be provided.
• Scoring: the number of conditions for which
guideline use can be documented (3 points
possible)
– 100%: 3 conditions
– 50%: 2 conditions
– 25%: 1 condition
3B: The practice uses a system with
guideline-based reminders for the
following services when seeing the patient
(Must Pass):
1. Age-appropriate screening tests
2. Age-appropriate immunizations (e.g.,
influenza, pediatric)
3. Age-appropriate risk assessments (e.g.,
smoking, diet, depression)
4. Counseling (e.g., smoking cessation)
Documentation of 3B
• Show that clinicians have decision support
available for all patient interactions, including inperson appointments, phone calls and e-mail
communication (if offered). Screenshots of visit
and phone templates, for example.
• Scoring: # of items for which reminders available
(4 points possible)
– 100%:
– 75%:
– 50%:
– 25%:
reminders for 4 items
reminders for 3 items
reminders for 2 items
reminders for 1 item
3C: The care team manages patient
care in the following ways:
1. Nonphysician staff remind patients of appointments
and collect information prior to appointments
2. Nonphysician staff execute standing orders for
medication refills, order tests and deliver routine
preventive services
3. Nonphysician staff educate patients/families about
managing conditions
4. Nonphysician staff coordinate care with disease
management or case management programs
Documentation of 3C
• Written job descriptions and protocols (tough
to score for practices that are solo-solo)
• Scoring: the number of items non-physician
staff manage (3 points possible)
– 100%: Staff manage 4 items
– 75%: Staff manage 3 items
– 50%: Staff manage 2 items
3D: For the three clinically important conditions,
the physician and nonphysician staff use the
following components of care management
support:
1. Conducting pre-visit planning with clinician
reminders
2. Writing individualized care plans
3. Writing individualized treatment goals
4. Assessing patient progress toward goals
5. Reviewing medication lists with patients
6. Reviewing self-monitoring results and incorporating
them into the medical record at each visit
3D: Care Management Support for
3 Identified Conditions (cont.):
7. Assessing barriers when patients have not met
treatment goals
8. Assessing barriers when patients have not filled,
refilled or taken prescribed medications
9. Following up when patients have not kept
important appointments
10. Reviewing longitudinal representation of patient’s
historical or targeted clinical measurements
11. Completing after-visit follow-up
Documentation of 3D
• Chart Review or EMR Reports
• Scoring: % of patients seen in last three months
with the identified conditions that have at least
4 items documented (5 points possible)
– 100%:
– 75%:
– 50%:
– 25%:
75% of patients have 4 items documented
50%-74% have 4 items documented
25%-49% have 4 items documented
10%-24% have 4 items documented
3E: The practice engages in the following
continuity of care activities for patients
who receive care in outside facilities or
who are transitioning to other care:
1. Identifies patients who receive care in facilities
2. Systematically sends clinical information to the
facilities with patients as soon as possible
3. Reviews information from facilities (discharge
summary or ongoing updates) to determine
patients who require proactive contact outside of
patient-initiated visits or who are at risk for adverse
outcomes
4. Contacts patients after discharge from facilities
3E: Continuity of Care (cont.)
5. Provides or coordinates follow-up care to patients/families
who have been discharged
6. Coordinates care with external disease management or case
management organizations, as appropriate
7. Communicates with patients/families receiving ongoing
disease management or high risk case management
8. Communicates with case managers for patients receiving
ongoing disease management or high risk case management
9. For patients transitioning to other care, develops a written
transition plan in collaboration with the patient and family
10. Aids in identifying a new primary care physician or specialists
or consultants and offers ongoing consultation
Documentation for 3E
• Written protocols for the 10 listed items
• Chart review showing compliance with the
protocols
• Scoring: # of items protocols and compliance
are documented: (2 points possible)
– 100%: 5 – 10 items documented
– 75%: 3 – 4 items documented
– 50%: 2 items documented
Standard 4: Patient SelfManagement Support
• 4A: The practice assesses patient/familyspecific barriers to communication using a
systematic process to:
1. Identify and display in the record the language
preference of the patient and family
2. Assess both hearing and vision barriers to
communication
Documentation of 4A (Barriers to
Communication)
• Screen shots, summary sheets, or EMR reports
showing language preference, assessment of
hearing or vision barriers, and perhaps literacy
assessment.
• Scoring: # of items the practice assesses (2
points possible)
– 100%: 2 items assessed
– 50%: 1 item assessed
4B: The practice conducts activities to
support patient/family self-management,
for the three important conditions
(Must Pass):
1. Assess patient/family preferences, readiness to
change and self-management abilities
2. Provides educational resources in the language or
medium that the patient/family understands
3. Provides self-monitoring tools or personal health
record, or works with patients’ self-monitoring tools
or health record, for patients/families to record
results in the home setting where applicable
4B: Support of Self-Management
(Must Pass)
4. Provides or connects patients/families to selfmanagement support programs
5. Provides or connects patients/families to classes
taught by qualified instructors
6. Provides or connects patients/families to other selfmanagement resources where needed
7. Provides written care plan to the patient/family
Documenting 4B
• % of patients with a clinically important
condition seen in the last 3 months with these
activities documented in the last 14 months
• Scoring: % of patients seen in 3 months who
have 3 activities documented (4 points
possible)
– 100%:
– 75%:
– 50%:
– 25%:
75%-100% have 3 activities documented
50%-74% have 3 activities documented
25%-49% have 3 activities documented
11%-24% have 3 activities documented
Standard 5: Electronic Prescribing
• 5A: The practice uses an electronic system to
write prescriptions either:
1. Electronic prescription writer – stand-alone
system (general) with either print capability at
the office or ability to send fax or electronic
message to pharmacy
2. Electronic prescription writer that is linked to
patient-specific demographic and clinical
information
Documenting 5A
• % of prescriptions written in last 3 months
using item 1 or 2
• Scoring: (3 points possible)
– 100% 75%-100% new Rxs using item 2
– 75%: 75%-100% new Rxs using item 1
5B: Electronic prescription reference
information at the point of care includes the
following types of alerts and information:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Drug-drug interactions based on general information
Drug-drug interactions specific to drugs the patient takes
Drug-disease interactions based on general information
Drug-disease interactions specific to diseases the patient has
Drug-allergy alerts based on general information
Drug-allergy alerts specific to the patient
Drug-patient history alerts based on general information
Appropriate dosing based on general information
Appropriate dosing calculated for the patient
5B: Electronic Prescribing Resources
(continued)
10. Therapeutic monitoring associated with specific drug
utilization based on general information (drug-lab alerts)
11. Duplication of drugs in a therapeutic class based on general
information
12. Duplication of drugs in a therapeutic class specific to the
patient
13. Drugs to be avoided in the elderly based on general
information
14. Drugs to be avoided in the elderly based on age of the
patient
Documenting 5B
• Documentation includes reports from the
electronic prescription system showing an
example of use of each item.
• Scoring: the number of alerts/information
used by the practice: (3 points possible)
– 100%:
– 75%:
– 50%:
– 25%:
8 or more alerts/information used
4 – 7 alerts/information used
2 – 3 alerts/information used
system has capacity for 6+, but not used
5C: Clinicians engage in cost-effective
prescribing through one or more of the
following tools:
1. Electronic prescription writer with general
automatic alerts for different choices
including generics
2. Electronic prescription writer connected to
payer-specific formulary that automatically
alerts clinician to alternative drugs, including
generics
Documentation of 5C
• Reports from the system, screen shots,
protocols showing cost-efficient prescribing
choices including generic drugs.
• Scoring 5C: (2 points possible)
– 100%: prescription writer has automatic alerts
and payor-specific formulary information
– 75%: prescription has automatic alerts or payorspecific formulary information
Standard 6: Test Tracking
• 6A: The practice systematically tracks tests
and follows up in the following manner (Must
Pass):
1. Tracks all laboratory tests ordered or done within the
practice, until results are available , flagging overdue results
2. Tracks all imaging tests ordered or done within the practice,
until results are available , flagging overdue results
3. Flags abnormal test results, bringing them to a clinician’s
attention
4. Follows up with patients/families for all abnormal test results
5. Follows up with inpatient facility on hearing screening and
metabolic screening to get results
6. Notifies patients/families of all normal test results
Documentation of 6A
• Documentation of system used to track test
completion, flagging of abnormal results, and
proactive notification of the patient of all results.
• Can include logs, spreadsheets, reports,
screenshots, written protocols
• Scoring: (7 points possible)
– 100%: Practice does 4 – 6 types of tracking
– 50%: Practice does 3 types of tracking
– 25%: System has capability (4+ types), but not used
6B: Electronic test ordering and
retrieval system used to:
1.
2.
3.
4.
5.
6.
Order lab tests
Order imaging tests
Retrieve lab results directly from source
Retrieve imaging text reports directly from source
Retrieve images directly from the source
Route and manage current and historical test
results to appropriate clinical personnel for review,
filtering and comparison
7. Flag duplicate tests ordered
8. Generate alerts for appropriateness of tests ordered
Documentation of 6B
• Screen shots or reports showing examples of
each function
• Scoring: number of functions used (6 points
possible)
– 100%: 5 – 8 functions used
– 75%: 3 – 4 functions used
– 50%: 1 – 2 functions used
Standard 7: Referral Tracking
• 7A: The practice uses a system to assist in tracking
referrals designated as critical until reporting
completed, including the following (Must Pass):
1. Origination
2. Clinical details
•
•
•
•
•
•
•
•
Reason for the consultation
Pertinent clinical findings
Support person
Functional status
Family history
Social history
Plan of care
Health care providers
7A: Referral Tracking System
(continued)
3. Tracking status
– Receipt of consultant’s report
4. Administrative details
– Insurance information, including whether the
referral requires health plan approval
Documentation of 7A
• System reports, protocols. Paper follow-up
log. Note this is specific to critical referrals.
• Scoring: number of items tracked (4 points
possible)
– 100%: 4 items tracked
– 75%: 2 – 3 items tracked
– 50%: 1 item tracked
Standard 8: Performance Reporting
and Improvement
• 8A: The practice measures or receives data on
the following types of performance by
physician or across the practice (Must Pass):
1. Clinical process (e.g., percentage of women 50+
with mammograms or childhood vaccination
rates)
2. Clinical outcomes (e.g., HbA1c levels for
diabetics)
3. Service data (e.g., backlogs or wait times)
4. Patient safety issues (e.g., medication errors)
Documentation for 8A
• Performance measurement of all eligible
patients required. Sources include reports
from manual record review, PMS reports,
registries, health plan data, EMR reports.
• Scoring: # of types of performance measured
(3 points possible)
– 100%: At least 2 types of performance measured
– 50%: One type of performance measured
8B: Collects patient experience data in
the following areas:
1. Patient access to care
– Ability to make an appointment and see a physician
– Timeliness and quality of phone calls
– Office wait time
2. Quality of physician communication
– Responses to patient and family questions
– Instructions and information about diagnosis, treatment,
medication and follow-up care
– The degree to which patients and families feel that they
are partners in health-care management
8B: Patient Experience Data (cont.)
3. Patient/family confidence in self care
– Patient knowledge of and ability to provide selfcare involving activity, exercise, medications and
reporting changes in their symptoms
4. Patient/family satisfaction with care
– Satisfaction with staff, physician and others
– Satisfaction with treatment
– Satisfaction with response to patient/family
choices
The Irony of 8B
• The 4 data items listed in 8B are the pillars of
a high-performing health care system:
– Access
– Efficiency
– Continuity
– Good information
– Coordination
• Yet, this is not a Must-Pass item, and it only
accounts for 3% of points in the NCQA
scheme.
Documentation of 8B
• Phone, paper or electronic survey reflecting
experience of sampling of all patients in
practice with summary of results. (Could use
Hows YourHealth? for validated data or Survey
Monkey for quick and dirty survey.)
• Scoring: number of areas of data collected (3
points possible)
– 100%: Data collected on 3 – 4 areas
– 50%: Data collected on 1 – 2 areas
HowsYourHealth.com
HowsYourHealth.com
Population Summary Report
HYH Population Summary Data
8C: The Practice Reports on
Performance on the Measures in
8A and 8B (Must Pass):
1. Across the practice
2. By individual physician
Documentation for 8C
• Copies of blinded reports showing individual
physician and summary practice performance.
Must be representative of entire patient base.
• Scoring: (3 points possible)
– 100%: Both summary and individual reports
produced
– 50% Either summary or individual reports
produced
8D: The practice uses performance
data to:
1. Set goals based on measurement results
referenced in Elements 8A and 8B
2. Take action, where identified, to improve
performance of individual physicians or of
the practice as a whole
Documentation for 8D
• Reports, or completion of the PPC Quality Measurement
and Improvement worksheet, should demonstrate that
the practice sets goals, measures progress and takes
action, including periodic remeasurement to promote
continuous quality improvement.
• Scoring: (3 points possible)
– 100%: Documentation of setting goals and taking
action
– 50%: Documentation of setting goals or taking action
8E: Performance reports produced using
nationally approved clinical performance
measures
• Currently, NCQA only accepts National Quality
Forum (NQF)-endorsed performance
measures. The NQF-endorsed National
Voluntary Consensus Standards for
Ambulatory Care for use at the physician or
practice level are available online.
Documentation of 8E
• Reports showing practice-level performance
on the measures you have selected.
• Scoring: number of measures in produced
reports (2 points possible)
– 100%: 10 or more measures reported
– 75%: 5 – 9 measures reported
– 50%: 3 – 4 measures reported
8F: Electronic reporting of results on
nationally approved measures to the public
sector, health plans or others.
• Documentation (this is simply 8E electronically
submitted):
– A report transmitted from the practice’s electronic
system to a payer or other external entity.
• Scoring: number of measures transmitted (1
point possible)
– 100%: 10 or more measures transmitted
– 75%: 5 – 9 measures transmitted
– 50%: 3 – 4 measures transmitted
Standard 9: Advanced Electronic
Communication
• 9A: The practice provides patients/families
with access to an interactive Web site that
allows them to:
1.
2.
3.
4.
5.
6.
Request appointments by reviewing clinicians schedules
Request referrals
Request test results
Request prescription refills
See elements of their medical record
Import elements of their medical record into a personal
health record
Documentation for 9A
• Screen shots of the web site showing each
function
• Scoring: number of items provided (1 point
possible)
– 100%: 5 – 6 items provided
– 75%: 3 – 4 items provided
– 50%: 1 – 2 items provided
Online Appointment Scheduling
Online Appointment Scheduling
Online Appointment Scheduling
Patient View of Chart using WebView
Documentation for 9B
• Screen shots showing identification of patients
in each category and examples of generated email.
• Scoring: number of items demonstrated (2
points possible)
– 100%: 5 – 6 items documented
– 75%: 3 – 4 items documented
– 50%: 1 – 2 items documented
Advanced Electronic Communication at the
Exam Room Desk
9B: Combining electronic information and
clinical decision-support technologies to
contact various types of patients by e-mail:
1.
2.
3.
4.
5.
6.
Patients needing clinical review or action
Patients on a particular medication
Patients needing preventive care
Patients needing specific tests
Patients needing follow-up visits
Patients who might benefit from disease or
case management support
9C: For patients with the three clinically
important conditions, the practice uses
electronic communication for the
following:
1. To communicate with disease or case
managers about patient needs
2. Web-based educational modules for patient
self-management
Documentation for 9C
• Screen shots of communications with disease
or case managers. Links to web-based
education modules for the 3 conditions,
recommended to the patients
• Scoring: (1 point possible)
– 100%: electronic communication used for 2 items
– 75%: electronic communication used for 1 item
Conclusions
• NCQA recognition as an Advanced Medical
Home is not particularly difficult, but is very
time consuming and is expensive, especially
for a small practice where the physician will be
doing much of the work.
• Only a small percentage of the points counted
actually relate to activities that define a highperforming primary care system.
Conclusions
• The vast majority of the points counted relate
to how sophisticated the practice’s EMR is,
and whether the practice has staff devoted to
writing administrative policies, not to whether
the practice performs well.
• The level of evidence supporting this concept
is far below the standard which physicians are
expected to use for clinical decisions.
• There is a potential for some financial benefit
to achieving recognition, though this remains
to be seen.
Thank You
Questions?