PCMH Proposed 2014 Standards

Use Proposed Requirement (Column 2) element names when participating in public comment.
Current Requirement Proposed Requirement PCMH 1: Enhance Access and Continuity PCMH 1A: Access During Office Hours PCMH 1A: Access During Office Hours The practice has a written process and defined standards, and demonstrates that it monitors performance against the standards for: 1. Providing same-day appointments 2. Providing timely clinical advice by telephone during office hours 3. Providing timely clinical advice by secure electronic messages during office hours 4. Documenting clinical advice in the medical record. Documentation Factors 1-4: Documented process for scheduling appointments, providing clinical advice and documenting advice and Factors 1-3: Reports with 5 days of data showing same-day access, response times compared to practice defined standards Factor 4: Three examples of clinical advice or report with percent documented advice in record in recent one month period Scoring 4 factors = 100% 3 factors (including Factor 1) = 75% 2 factors (including Factor 1)= 50% Factor 1 = 25% (not 1 factor) 0 factors or missing Factor 1 = 0% CRITICAL FACTOR = FACTOR 1 The practice has a written process and defined standards, and demonstrates that it monitors performance against the standards for: 1. Providing same-day appointments 2. Providing timely clinical advice by telephone during office hours 3. Providing timely clinical advice by secure electronic messages during office hours 4. Documenting clinical advice in the patient medical record 5. Providing non-traditional types of clinical encounters 6. Appointment wait times Documentation Factors 1-6: Documented process and Factors 1-3: Reports with at least 5 days of data showing same-day access (1), response times compared to practice defined standards (2,3), appointment wait times compared to practice defined standards (6) Factor 4: Three examples of clinical advice or report with percent documented advice in record in recent one month period Factor 5: Report with frequency of non-traditional encounters in a recent one month period. Scoring 5-6 factors (including Factor 1) = 100% 4 factors (including Factor 1) = 75% 2 factors (including Factor 1) = 50% Factor 1 (not just any 1 factor) = 25% 0 factors or missing Factor 1 = 0% CRITICAL FACTOR = FACTOR 1
Key: Proposed Additions Proposed Deletions Recommendations Add Factor 5: "Providing non-traditional types of clinical encounters" to encourage practices to expand accessibility for patients beyond the traditional oneon-one, face-to-face visits. Examples include structured e-visits, shared medical appointments, group visits, scheduled telephone encounters, video visits. This does NOT include asynchronous communication such as secure email. The reference to group visits currently in PCMH 4B factor 4 will be removed to avoid duplication and confusion. Factors added to the Access standard in PCSP (Provide equal access to accepted patients regardless of source of payment & Provide uninsured patients with information about obtaining coverage) have been added in Element E: Medical Home Responsibilities. Including a minimum expectation for the number of same-day appointments was discussed but determined to be unnecessarily prescriptive. There was also discussion of adding a factor to require monitoring 'no show' rates but it was determined this would also be too prescriptive and instead we should highlight in the explanation how monitoring and reducing no show rates can assist in improving appointment access. Ideally practices should monitor patient preferences and demand and use this information to model supply of services and appointments. Do the proposed standards sufficiently encourage this? The explanation will also be updated to note how this element connects with performance measurement/improvement expectations in the new Standard 5.
NCQA PCMH Proposed Standards Obsolete After July 22, 2013
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement PCMH 1B: After Hours Access PCMH 1 B: After Hours Access The practice has a written process and defined standards, and demonstrates that it monitors performance against the standards for: 1. Providing access to routine and urgent-care appointments outside regular business hours 2. Providing continuity of medical record information for care and advice when the office is not open 3. Providing timely clinical advice by telephone when the office is not open 4. Providing timely clinical advice using a secure, interactive electronic system when the office is not open 5. Documenting after-hours clinical advice in patient records. Documentation Factors 1-5: Documented process for arranging afterhours access, making medical records available after hours, providing timely advice after hours, documenting advice after hours and Factor1: Report showing after hours availability or materials with after-hours care Factors 3,4: Report showing after hours calls/emails, response times Factor 5: Three examples of clinical advice or report with percent documented advice in record in recent one month period Scoring 5 factors = 100% 4 factors (including Factor 3) = 75% 3 factors (including Factor 3) = 50% 1-2 factors = 25% 0 factors = 0% CRITICAL FACTOR = FACTOR 3 The practice has a written process and defined standards and demonstrates that it monitors performance against the standards for: 1. Providing access to routine and urgent-care appointments outside regular business hours 2. Providing continuity of medical record information for care and advice when office is not open 3. Providing timely clinical advice by telephone when the office is not open 4. Providing timely clinical advice using a secure, interactive electronic system when the office is not open 5. Documenting after-hours clinical advice in patient records Documentation Factors 1-5: Documented process for arranging afterhours access, making medical records available after hours, providing timely advice after hours, documenting advice after hours and Factor 1: Report showing after hours availability or materials with after-hours care Factors 3,4: Report showing after hours calls/emails, response times Factor 5: Three examples of clinical advice or report with percent documented advice in record in recent one month period Scoring 5 factors = 100% 4 factors (including Factor 3) = 75% 3 factors (including Factor 3) = 50% 1-2 factors = 25% 0 factors = 0% CRITICAL FACTOR = FACTOR 3
Key: Proposed Additions Proposed Deletions Recommendations Maintain current requirement. Should we consider combining this element with Element A and moving factors related to continuity of medical record information to Element 1D: Continuity?
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement PCMH 1C: Electronic Access PCMH 1C: Electronic Access The practice provides the following information and services to patients and families through a secure electronic system. 1. More than 50 percent of patients who request an electronic copy of their health information (including problem list, diagnoses, diagnostic test results, medication lists, allergies) receive it within three business days 2. At least 10 percent of patients have electronic access to their current health information (including lab results, problem list, medication lists, and allergies) within four business days of when the information is available to the practice 3. Clinical summaries are provided to patients for more than 50 percent of office visits within three business days 4. Two-way communication between patients/families and the practice 5. Request for appointments or prescription refills 6. Request for referrals or test results Documentation Factors 1-3: Report showing percentage of patients who received electronic copy of health information, access to requested health information, electronic clinical summaries (NA for factor 1 if no requests in reported time period) Factors 4-6: Screen shots of its secure web site or portal, web page where patients can make requests and communication capability with patients Scoring: 5-6 factors = 100% 3-4 factors = 75% 2 factors = 50% 1 factor = 25% 0 factors = 0% The practice provides the following information and services to patients/families/caregivers through a secure electronic system. 1. More than 50 percent of patients have online access to their health information within four business days of when the information is available to the practice+ 2. More than 5 percent of patients view, and are provided the capability to download, their health information or transmit their health information to a third party+ 3. Clinical summaries are provided within 1 business day(s) for more than 50 percent of office visits+ 4. A secure message was sent to more than 5 percent of patients+ 5. Two-way communication with the practice 6. Request for appointments, prescription refills, referrals and test results + Stage 2 Core Meaningful Use Requirement Documentation Factors 1-4: Report based on numerator and denominator for a recent 12 months (or 3 months) of data in the electronic system Factors 5 and 6: Screen shots showing the capability of the practices system. Scoring 5-6 factors = 100% 3-4 factors = 75% 2 factors = 50% 1 factor = 25% 0 factors = 0%
Key: Proposed Additions Proposed Deletions Recommendations Add "caregivers" to Element Stem to be consistent with the rest of the standards. Update the factors to reflect Stage 2 MU and align with Patient-Centered Specialty Practice (PCSP) element 2B. This includes: x x x x x x x deleting current factor 1, renumbering current factor 2 to factor 1 and updating percentage, adding a new factor 2, updating factor 3 to require clinical summaries within 1 day, adding a new factor 4, renumbering current factor 4 to factor 5 and combining current factors 5 & 6 into a single factor requiring all four services to be available to qualify for credit.
Note in explanation that electronic access is subject to privacy rules for adolescents. Also note that the practice can establish its own policies regarding the release of test results (for example abnormal results may be held back from electronic posting until the clinician can discuss them with the patient directly). If you believe there are other electronic functions that should be included in this element please be specific and if possible provide a real-life example of a system that provides the function.
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement PCMH 1D: Continuity PCMH 1D: Continuity The practice provides continuity of care for patients/families by: 1. Expecting patients/families to select a personal clinician 2. Documenting the patients/familys choice of clinician 3. Monitoring the percentage of patient visits with a selected clinician or team. Documentation Factor 1: Documented process or materials for clinician selection Factor 2: Screen shot showing patients choice of clinician Factor 3: Report showing patient encounters with designated clinician or team (minimum 1 wk. of data or equivalent) Scoring: 3 factors = 100% 2 factors = 50% 1 factor = 25% 0 factors = 0% Solo practitioners may mark yes for all factors and indicate that they are the sole personal clinician for the practice in the Comments for full credit. The practice provides continuity of care for patients/families by: 1. Expecting patients/families to select a personal clinician and documenting the selection in practice records 2. Documenting the patients/familys choice of clinician 3. 2. Monitoring the percentage of patient visits with selected clinician or team. 3. Confirming panels regularly 4. Having a process to orient patients new to the practice Documentation Factor 1: Documented process or materials for clinician selection and Screen shot showing documentation of patient's choice of clinician Factor 2: Report showing patient encounters with designated clinician or team (minimum 1 wk. of data or equivalent) Factor 3: Documented process for regular (defined by the practice) review of patient panel assignments. This may include review of panel lists from payers to identify new patients as well as to identify and notify payers of patients known to have left the practice. Factor 4: Documented process outlining the process to orient or 'onboard' patients new to the practice. This includes distribution of the practices materials on medical home responsibilities and patient expectations as well as guiding patients through the process of having any prior medical record information transferred to the practice. Scoring: TBD once final number of factors (4 or 6) is established. Anticipate all factors met for 100% and 25% score for meeting at least 1 factor. Solo practitioners may mark yes for factors 1 and 2 and indicate that they are the sole personal clinician for the practice in the Comments.
Key: Proposed Additions Proposed Deletions Recommendations NCQA's advisory committee suggested this element might be broadened to consider other features of continuity (relational, informational, clinical). While seeing your selected clinician/team (relational) is a critical component of good continuity, assuring access to the medical record by the clinician that does see a patient when their regular clinician is not available is also important for continuity of care. One suggestion was to pull factor 4 from element 1A and factors 2 & 5 from element 1B to include in this element instead. The new factors would be: #. Documenting clinical advice in patient records #. Providing continuity of medical record information for care and advice when the office is closed In addition, the importance of regularly confirming for which patients the practice has responsibility was raised. Two new factors are proposed in this element (factors 4 and 5) to address this issue.
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement PCMH 1E: Medical Home Responsibilities PCMH 1E: Medical Home Responsibilities The practice has a process and materials that it provides patients/families on the role of the medical home, which include the following: 1. The practice is responsible for coordinating patient care across multiple settings 2. Instructions on obtaining care and clinical advice during office hours and when the office is closed 3. The practice functions most effectively as a medical home if patients/families provide a complete medical history and information about care obtained outside the practice 4. The care team gives the patient/family access to evidence-based care and self-management support Documentation Factors 1-4: Documented process for providing information to patients and Factors 1-4: Patient materials Scoring: 4 factors = 100% 3 factors = 75% 2 factors = 50% 1 factor = 25% 0 factors = 0% The practice has a process and materials that it provides to patients/families on the role of the medical home, which include the following: 1. The practice is responsible for coordinating patient care across multiple settings 2. Instructions on obtaining care and clinical advice during office hours and when the office is closed 3. The practice functions most effectively as a medical home if patients provide a complete medical history and information about care obtained outside of the practice 4. The care team provides the patient/family with access to evidence-based care and self-management support 5. The scope of services available within the practice including how behavioral health needs are addressed 6. The practice will provide equal access to all of their patients regardless of source of payment 7. The practice will provide uninsured patients with information about obtaining coverage Documentation Factors 1-7: Documented process for providing information to patients and Factors 1-7: Patient materials Scoring: 6-7 factors = 100% 4-5 factors = 75% 2-3 factors = 50% 1 factor = 25% 0 factors = 0%
Key: Proposed Additions Proposed Deletions Recommendations Add new factor (5) identifying the scope of services offered by the practice and specifically identifying how behavioral health needs will be addressed. Add new factor (6) from PCSP (2A Factor 7) to address reports of unequal treatment. A practice should serve as a medical home for all of their patients, not just those with greater financial means. This factor does not require practices to accept every patient that seeks to join the practice but does expect the practice to treat all patients they do accept equally regardless of the source of payment. For example, a practice that restricts appointment availability to certain times or days of the week for Medicaid patients would not meet the intent of this factor. Add new factor (7) from PCSP (2A Factor 8) expecting the practice to provide information or guidance to patients who do not have or who lose their insurance coverage.
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement PCMH 1F: Culturally and Linguistically Appropriate PCMH 1F: Culturally and Linguistically Appropriate Services Services The practice engages in activities to understand and meet the cultural and linguistic needs of its patients/families by: 1. Assessing the racial and ethnic diversity of its population 2. Assessing the language needs of its population 3. Providing interpretation or bilingual services to meet the language needs of its population 4. Providing printed materials in the languages of its population Documentation Factors 1-4: Documented process for providing information to patients and Factors 1-4: Patient materials Scoring: 4 factors = 100% 3 factors = 75% 2 factors = 50% 1 factor = 25% 0 factors = 0% PCMH 1G: The Practice Team The practice uses a team to provide a range of patient care services by: 1. Defining roles for clinical and nonclinical team members 2. Having regular team meetings or a structured communication process 3. Using standing orders for services 4. Training and assigning care teams to coordinate care for individual patients 5. Training and assigning care teams to support patients and families in self-management, selfefficacy and behavior change
The practice engages in activities to understand and meet the cultural and linguistic needs of its patients/families. 1. Assessing the racial and ethnic diversity of its population 2. Assessing other cultural characteristics of its population 3. Assessing the language needs of its population 4. Providing interpretation or bilingual services to meet the language needs of its population 5. Providing printed materials in the languages of its population Documentation Factors 1-5: Documented process for providing information to patients and Factors 1-5: Patient materials Scoring: 5 factors = 100% 3-4 factors = 75% 2 factors = 50% 1 factor = 25% 0 factors = 0% PCMH 1G: The Practice Team The practice uses a team to provide a range of patient care services by: 1. Defining roles for clinical and nonclinical team members 2. Identifying practice organizational structure and staff leading and sustaining the practice transformation 3. Having regular team meetings or a structured communication process focused on patient care planning 4. Using standing orders for services 5. Training and assigning care teams to coordinate
Key: Proposed Additions Proposed Deletions Recommendations Expand the definition of 'culture' beyond race and ethnicity. This broadening is consistent with the recently released 'Enhanced CLAS Standards' from the Office of Minority Health and would be inclusive of sexual orientation. Per OMH 'Culture refers to the integrated pattern of thoughts, communications, actions, customs, beliefs, values and institutions associated, wholly or partially, with racial, ethnic or linguistic groups, as well as with religious, spiritual, biological, geographical or sociological characteristics. e.g. cognitive ability, educational level attained, gender identity, generation, political beliefs, residence, sexual orientation, socioeconomic status, etc.' Practices are not required to systematically assess all of these characteristics but rather may choose 'other cultural characteristics' deemed most relevant to their community. We propose to maintain the current expectations and add a new factor to address other cultural characteristics (beyond racial and ethnic diversity) that may relate to health beliefs, behaviors, preferences or needs.
This element was identified as a priority area for enhancement in the 2014 standards in recognition of the important role of practice culture in achieving and sustaining true transformation. Beyond the changes proposed here, NCQA anticipates reorganizing this element along with others that relate to the functioning of the practice (e.g. Continuity and Medical Home Responsibilities) into a separate standard to increase visibility and emphasis on these aspects of the medical home model. We welcome suggestions for other ways to effectively distinguish high-functioning teams. Add Factor 2 to ensure a deliberate process of involving the practice team in the process. Page 6 of 33
Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement care for individual patients 6. Training and assigning care teams for patient 6. Training and assigning care teams to support population management patients/families/caregivers in self-management, self7. Training and designating care team members in communication skills efficacy and behavior change 8. Involving care team staff in the practices 7. Training and assigning care teams for patient performance evaluation and quality improvement population management activities 8. Training and designating care team members in communication skills Documentation 9. Involving care team staff in the practices Factors 1, 4-7: Staff position descriptions or performance evaluation and quality improvement responsibilities activities Factor 2: Description of staff communication 10. Holding regular team meetings addressing processes and sample practice functioning Factor 3: Written standing orders Factors 4-7: Description of training process, Documentation schedule, materials Factors 1,2, 4-8: Staff position descriptions or Factor 8: Description of staff role in practice responsibilities improvement process or minutes demonstrating staff Factor 3: Description of staff communication involvement processes and sample of how pre-visit planning is conducted Scoring: Factor 4: Written standing orders 7-8 factors (including factor 2) = 100% Factors 5-8: Description of training process, 5-6 factors (including factor 2) = 75% schedule, materials 4 factors (including factor 2) = 50% Factor 9: Description of staff role in practice 2-3 factor = 25% improvement process or minutes demonstrating staff factors = 0% involvement CRITICAL FACTOR = FACTOR 2 Factor 10: Description of staff communication processes and sample Scoring: 10 factors (including factor 3) = 100% 8-9 factors (including factor 3) = 75% 5-7 factors (including factor 3) = 50% 2-4 factors = 25% 0-1 factor = 0 CRITICAL FACTOR = FACTOR 3
Key: Proposed Additions Proposed Deletions Recommendations Add language to Factor 3 to clarify that the team meetings are to focus on individual patients, not on practice operations. This includes pre-visit planning for specific patients. Add language to the explanation for factor 5 (now factor 6) referencing shared decision making and motivational interviewing. Add Factor 10 to encourage the practice to hold regular team meetings that focus on team-building and staff engagement.
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement PCMH 2: Identify and Manage Patient Populations PCMH 2A: Patient Information PCMH 2A: Patient Information The practice uses an electronic system that records the following as structured (searchable) data for more than 50 percent of its patients. 1. Date of birth 2. Gender 3. Race 4. Ethnicity 5. Preferred language 6. Telephone numbers 7. E-mail address 8. Dates of previous clinical visits 9. Legal guardian/health care proxy 10. Primary caregiver 11. Presence of advance directives (NA for pediatric practices) 12. Health insurance information Documentation F1-12: Report from electronic system showing the percentage of all patients for each populated data field. The report contains each required data item to determine how many factors are consistently entered (numerator and denominator showing > 50%) for a 12 mo. (or 3 mo. of data) sample of patients Scoring 9-12 factors = 100% 7-8 factors = 75% 5-6 factors = 50% 3-4 factors = 25% 0-2 factors = 0% The practice uses an electronic system that records the following as structured (searchable) data for more than 50/80 percent of its patients. 1. Date of birth+ 2. Gender Sex+ 3. Race+ 4. Ethnicity+ 5. Preferred language+ 6. Telephone numbers 7. E-mail address 8. Occupation 9. Dates of previous clinical visits 10. Legal guardian/health care proxy 11. Primary caregiver 12. Presence of advance directives (NA for pediatric practices) 13. Health insurance information 14. Name and contact information of other health care professionals involved in patient's care Documentation Factors 1-13 - Report with numerator and denominator with 12 months (or 3 months) of data Factor 14 does not need to be captured in structured data fields. Documentation should be a written process and screen shots identifying how and where this information is captured on patients and three examples. Scoring 10-14 factors = 100% 8-9 factors = 75% 5-7 factors = 50% 3-4 factors = 25% 0-2 factors = 0%
Key: Proposed Additions Proposed Deletions Recommendations Change percent of patients with data from 50% to 80% to align with Stage 2 Meaningful Use Change Factor 2: from Gender to Sex to align with Meaningful Use Add Factor 8: Occupation to encourage practices to document potential work-related implications for care planning, even in the case of retirees. This field might also reflect school for students where this information would be relevant for coordination. Add Factor 14: Name and contact information of specialists/consultants because it is important information for primary care practices to document in the patient medical record. The advisory committee specifically requested we include the broader terminology to capture other providers that might be important to coordinate with for specific patients. Other factors have been renumbered to accommodate the new factors but are otherwise unchanged. While there were some additional fields recommended by some for inclusion on this list (e.g., gender in addition to sex), others strongly advised against this.
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement PCMH 2B: Clinical Data PCMH 2B: Clinical Data The practice uses an electronic system to record the following as structured (searchable) data. 1. An up-to-date problem list with current and active diagnoses for more than 80 percent of patients 2. Allergies, including medication allergies and adverse reactions, for more than 80 percent of patients 3. Blood pressure, with the date of update for more than 50 percent of patients 2 years and older 4. Height for more than 50 percent of patients 2 years and older 5. Weight for more than 50 percent of patients 2 years and older 6. System calculates and displays BMI (NA for pediatric practices) 7. System can plot and display growth charts (length/height, weight and head circumference (less than 2 years of age) and BMI percentile (220 years) (NA for adult practices) 8. Status of tobacco use for patients 13 years and older for more than 50 percent of patients (NA for pediatric practices if all patients 9. List of prescription medications with the date of updates for more than 80 percent of patients Documentation Factors 1-5, 8-9: Reports with a numerator and denominator Factors 6, 7: Screen shots demonstrating capability Scoring 100% - 9 factors 75% - 7-8 factors 50% - 5-6 factors 25% - 3-4 factors 0% - 0-2 factors The practice uses an electronic system to record the following as structured (searchable) data. 1. An up-to-date problem list with current and active diagnoses for more than 80 percent of patients 2. Allergies, including medication allergies and adverse reactions* for more than 80 percent of patients 3. Blood pressure, with the date of update for more than 50/80 percent of patients 3 years and older+ 4. Height/length for more than 50/80 percent of patients 2 years and older+ 5. Weight for more than 50/80 percent of patients 2 years and older+ 6. System calculates and displays BMI + 7. System plots and displays growth charts (length/height, weight and head circumference) (less than 2 years of age) and BMI percentile (0-20 years) (NA for adult practices)+ 8. Status of tobacco use for patients 13 years and older for more than 50/80 percent of patients+ 9. List of prescription medications with date of updates for more than 80 percent of patients 10. More than 20 percent of patients have family history recorded as structured data++ 11. At least one electronic progress note created, edited and signed by an eligible professional for more than 30 percent of patients with at least one office visit++ + Stage 2 Core Meaningful Use Requirement ++ Stage 2 Menu Meaningful Use Requirement Documentation Factors 1-5, 8-11: Reports with a numerator and denominator Factors 6, 7: Screen shots demonstrating capability Scoring 100% - 9-11 factors 75% - 7-8 factors
Key: Proposed Additions Proposed Deletions Recommendations Update to reflect Stage 2 MU. Include in explanation that factor 1 should reflect medical and behavioral diagnoses.
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement 50% - 5-6 factors 25% - 3-4 factors 0% - 0-2 factors
Key: Proposed Additions Proposed Deletions Recommendations
INTENTIONALLY LEFT BLANK
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement PCMH 2C: Comprehensive Health Assessment PCMH 2C: Comprehensive Health Assessment To understand the health risks and information needs of patients/families, the practice conducts and documents a comprehensive health assessment that includes: 1. Documentation of age- and gender-appropriate immunizations and screenings 2. Family/social/cultural characteristics 3. Communication needs 4. Medical history of patient and family 5. Advance care planning (NA for pediatric practices) 6. Behaviors affecting health 7. Patient and family mental health/substance abuse 8. Developmental screening using a standardized tool (NA for practices with no pediatric patients) 9. Depression screening for adults and adolescents using a standardized tool Documentation Factors 1-9: Process to show how information collected or completed patient assessment (deidentified) Scoring 8-9 factors = 100% 6-7 factors = 75% 4-5 factors = 50% 2-3 factors = 25% 0-1 factors = 0% To understand the health risks and information needs of patients/families, the practice collects and regularly updates a comprehensive health assessment that includes: 1. Documentation of age- and gender appropriate immunizations and screenings 2. Family/social/cultural characteristics 3. Communication needs 4. Medical history of patient and family 5. Advance care planning (NA for pediatric practices) 5. 6. Behaviors affecting health 6. 7. Patient and family mental health/substance abuse Mental health/substance use history of patient and family 7. 8. Developmental screening using a standardized tool (NA for practices with no pediatric patients) 8. 9. Depression screening for adults and adolescents using PHQ2, PHQ9 or other standardized tool Documentation Factors 1-8: Documented process to show how information is routinely collected on patients or completed patient assessment (deidentified) and Factors 1-8: Reports with at least 5 days of data Scoring 8 factors = 100% 6-7 factors = 75% 4-5 factors = 50% 2-3 factors = 25% 0-1 factors = 0% Explanation for factor 2 should be broad to include poverty, homelessness, unemployment, LGBTQ, education, social support. Explanation for factor 5 should include sexual behaviors.
Key: Proposed Additions Proposed Deletions Recommendations Clarify intent that health assessment information should be regularly updated, not just collected one time. Delete Factor 5: Advance care planning since advanced directives is in PCSP 2B. Modify Factor 7 (now 6) to parallel wording of factor 4. Add language to Factor 9 (now 8) naming PHQ2 and PHQ9 to encourage the use of these well validated tools. Add 'Reports' to documentation requirements for all factors to communicate expectation that such information is routine collected and updated for all patients. Note there was significant discussion of the importance that this information not only be collected but actually used. Element 2D (as well as care management and self management support) is intended to reflect the actions taken using available information so action steps were not added to this element. There was also some discussion of adding specific screening expectations for health behaviors, BMI, smoking, etc. Given that tobacco use and BMI are required in 2B we have elected not to include other items at this time.
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement Element 2D: Use Data for Population Management PCMH 2D: Use Data for Population Management The practice uses patient information, clinical data and evidence-based guidelines to generate lists of patients and to proactively remind patients/families and clinicians of services needed for: 1. At least three different preventive care services ++ 2. At least three different chronic care services ++ 3. Patients not recently seen by the practice 4. Specific medications. Documentation Factors 1-4: Lists or summary reports of patients who need services within past 12 mo. (Health plan data okay if 75% of patient population) Must include at least three different immunizations/ screenings and three different acute/chronic care services Factors 1-4: Materials demonstrating patient notification (letter, phone call script, screen shot of enotice) Scoring 4 factors = 100% 3 factors = 75% 2 factors = 50% 1 factors = 25% 0 factors = 0% NEW! The practice proactively identifies populations of patients and reminds them or their families/caregivers of needed care based on patient information, clinical data, health assessments and evidence-based guidelines including: 1. At least three two different preventive care services+ 2. At least two different immunizations+ 3 2. At least three different chronic or acute care services+ 4 3. Patients not recently seen by the practice 5 4. Medication monitoring or alert Documentation Factors 1-5: Lists or summary reports of patients who need services within past 12 mo. (Health plan data okay if 75% of patient population) and Factors 1-5: Materials demonstrating patient notification (letter, phone call script, screen shot of enotice) Scoring 4-5 factors = 100% 3 factors = 75% 2 factors = 50% 1 factors = 25% 0 factors = 0% Element 2E: Care Reminders for MU The practice generates lists of patients and proactively reminds more than 10 percent of patients/families/caregivers for needed preventive/follow-up care+ + Stage 2 Core Meaningful Use Requirement Documentation: Report Scoring The practice generates lists and proactively reminds at least 10% of patients/families/caregivers = 100%
Key: Proposed Additions Proposed Deletions Recommendations Revise stem for clarity and add 'caregivers'. Note that factors are intended to assure practices use registries and proactive reminders to address a variety of health care needs, not to imply that, for example, ONLY two immunizations are important enough to address in this way. Separate factor 1 into 2 factors addressing immunizations and other preventive care services (two of each) Factor 4 (now 5): Modify wording and offer additional examples. Could be used for medication recalls or warnings, reminders for necessary monitoring due to medication use (e.g., warfarin, liver function test for patients on selected meds, growth hormone).
New element created to address specific target percentage receiving reminders as defined in Stage 2 Meaningful Use.
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement PCMH 2F: Implement Evidence-Based Decision PCMH 3A: Implement Evidence-Based Guidelines Support The practice implements evidence-based guidelines through point-of-care reminders for patients with: The practice implements clinical decision support (e.g. point-of-care reminders) following evidence1. The first important condition based guidelines for: 2. The second important condition 3. The third condition, related to unhealthy behaviors 1. A mental health or substance use disorder or mental health or substance abuse. 2. A chronic medical condition 3. An acute condition Documentation 4. A condition related to unhealthy behaviors Factors 1-3: Identification of 3 conditions 5. Well child or adult care Factors 1-3: Name and source of guidelines 6. Overuse/appropriateness issues Factors 1-3: Demonstrate how guidelines are used (e.g. charting tools, screen shots, workflow Documentation organizers, condition-specific templates for treatment Factors 1-6: Demonstrate how guidelines plans/patient progress) are implemented (e.g. charting tools, screen shots, workflow organizers, condition-specific templates for Scoring treatment plans/patient progress monitoring) 3 factors = 100% 2 factors (including factor 3)= 50% Scoring 1 factor = 25% 5-6 Factors (including factor 1) =100% 0 factors = 0% 4 Factors (including factor 1) = 75% CRITICAL FACTOR = FACTOR 3 3 Factors (including factor 1)= 50% 1-2 Factors (including factor 1) = 25% 0 Factors or does not meet factor 1= 0% CRITICAL FACTOR = FACTOR 1
Key: Proposed Additions Proposed Deletions Recommendations Move Element 3A to a new Element 2F, with a number of edits. Intent is to emphasize a need to embed guidelines in daily practice tools and have such tools address a broad spectrum of clinical issues. This move will separate the requirement from the chart review for care management and self-care support. We have heard that in practice, all individuals with conditions supported by evidence based guidelines do not necessarily require added resources associated with care management and likewise some of those who can most benefit from care management services do not necessarily have a chronic condition supported by clinical guidelines. The changes we propose should provide practices with greater flexibility to identify the subset of their patients who can most benefit from these additional services while still providing meaningful support for individual and population-based health interventions (through 2D & 2F). Split prior factor 3 into two factors (1 & 4) encouraging practices to address both a health behavior issue (smoking, obesity) and a mental health/substance use disorder (depression, addiction, ADHD). Add new factor (6) to encourage focus on issues of appropriateness and overuse. This might include implementation of the Choosing Wisely initiative of the ABIM Foundation.
NOTE: There is a MU Objective which requires implementation of "five clinical decision support interventions related to four or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period." Meeting 5 factors in this element would seem to meet this MU Objective but it would be possible to meet MU without meeting 5 factors in this element. Should NCQA include a separate element that would specifically capture the MU expectation to maintain full alignment?
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement PCMH 3: Plan and Manage Care PCMH 3A: Identify High-Risk Patients for Care PCMH 3B: Identify High-Risk Patients Planning To identify high-risk or complex patients, the practice: The practice establishes criteria and a systematic 1. Establishes criteria and a systematic process to process to identify patients for care planning and the identify high-risk or complex patients defined criteria include the following: 2. Determines the percentage of high-risk or complex patients in its population. 1. Behavioral health 2. High cost/utilization Documentation 3. Social determinants of health Factor 1: Criteria and process to identify patients 4. Poorly controlled or complex conditions Factor 2: Report showing number and percentage of 5. Patients identified by outside organizations high-risk patients (insurers, health system, ACO) 6. The practice reports the percent of the total patient Scoring population identified using their criteria [critical 2 factors = 100% factor] 1 factor = 25% 0 factors = 0% Documentation Factors 1-5: Criteria and process to identify patients highlighting each of the criteria included in the factors Factor 2: Report showing number and percentage of patients identified Scoring 6 factors = 100% 4-5 factors (including factor 6) = 75% 2-3 factors (including factor 6) = 50% 1 factor = 25% 0 factors = 0%
Key: Proposed Additions Proposed Deletions Recommendations As noted in the proposed new element 2F (formerly 3A), NCQA is proposing to de-couple the 'three important conditions' from the care management and self-care support file review. Instead we intend to have practices define criteria to identify the patients most appropriate for this added support and use this list for the file review. This revised element will assess the scope/diversity of criteria used by the practice. Given the significant variation in distribution of risk in clinical practice, we do not propose to set a minimum threshold percentage of the patients identified using the practice's criteria but this rate must be reported to NCQA. Include behavioral health among examples of identification criteria.
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement PCMH 3B: Care Planning and Self-Care Support PCMH 3C: Care Management The care team performs the following for at least 75 percent of the patients identified in Elements A and B. 1. Conducts pre-visit preparations 2. Collaborates with the patient/family to develop an individual care plan, including treatment goals that are reviewed and updated at each relevant visit 3. Gives the patient/family a written plan of care 4. Assesses and addresses barriers when the patient has not met treatment goals 5. Gives the patient/family a clinical summary at each relevant visit 6. Identifies patients/families who might benefit from additional care management support 7. Follows up with patients/families who have not kept important appointments Documentation Factors 1-7: Report from electronic system or submission of Record Review Workbook Scoring - 75% of patients for each factor 6-7 factors = 100% 5 factors = 75% 3-4 factors = 50% 1-2 factors = 25% 0 factors = 0% The care team, along with the patient/family/caregiver, collaboratively develops and updates at relevant visits individualized care plans including the following features for at least 75 percent of the patients identified in Element 3A: 1. Incorporates patient preferences and functional/lifestyle goals 2. Identifies treatment goals 3. Assesses and addresses potential barriers to meeting goals 4. Includes self-management plan 5. Provided in writing to patient/family/caregiver Documentation Factors 1-5: Report from electronic system or submission of Record Review Workbook Scoring - 75% of patients for each factor 5 factors = 100% 4 factors = 75% 3 factors = 50% 1-2 factors = 25% 0 factors = 0%
Key: Proposed Additions Proposed Deletions Recommendations Modify element to focus on care plan features. Incorporate key aspects from current 3C and 4A requirements. Deleted factors are covered in other areas of the standards. For example factor 1 is addressed in The Practice Team. A question was raised on whether a new element or factor should be added elsewhere in the standards to address 'no show' policies including follow-up to assure the patient receives needed care. Current thinking is to include language about the importance of addressing no shows in the Access standard to encourage a systematic approach to reducing no show rates and thereby improve access and practice efficiency.
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement PCMH 3C: Medication Management PCMH 3D: Medication Management The practice manages medications in the following ways. 1. Reviews and reconciles medications with patients/families for more than 50 percent of care transitions 2. Reviews and reconciles medications with patients/families for more than 80 percent of care transitions 3. Provides information about new prescriptions to more than 80 percent of patients/families 4. Assesses patient/family understanding of medications for more than 50 percent of patients with date of assessment 5. Assesses patient response to medications and barriers to adherence for more than 50 percent of patients with date of assessment 6. Documents over-the-counter medications, herbal therapies and supplements for more than 50 percent of patients/families, with the date of updates Documentation Factors 1-6: Report from electronic system or submission of Record Review Workbook Scoring 5-6 factors (including factor 1) = 100% 3-4 factors (including factor 1) = 75% 2 factors (including factor 1) = 50% Factor 1 = 25% 0 factors or does not meet Factor 1 = 0% CRITICAL FACTOR = FACTOR 1 The practice has a process and demonstrates that it systematically manages medications 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. Reviews and reconciles medications with patients/families for more than 80 percent of care transitions. 3. Provides information about new prescriptions to more than 80 percent of patients/families/caregivers. 4. Assesses patient/family/caregiver understanding of medications for more than 50 percent with date of assessment 5. Assesses patient response to medications and barriers to adherence for more than 50 percent of patients with date of assessment 6. Documents over-the-counter medications, herbal therapies and supplements for more than 50 percent of patients with the date of updates. + Stage 2 Core Meaningful Use Requirement Documentation Factors 1-6: Report from electronic system or submission of Record Review Workbook Scoring 5-6 factors = 100% 3-4 factors = 75% 2 factors = 50% Factor 1 = 25% 0 factors or does not meet Factor 1 = 0% CRITICAL FACTOR = FACTOR 1
Key: Proposed Additions Proposed Deletions Recommendations Change Stem: has a process and demonstrates that it systematically to reflect the language in PatientCentered Specialty Practice (PCSP) recognition and to better align with Meaningful Use.
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement PCMH 3D: Use Electronic Prescribing PCMH 3E: Use Electronic Prescribing The practice uses an electronic prescription system with the following capabilities. 1. Generates and transmits at least 40 percent of eligible prescriptions to pharmacies 2. Generates at least 75 percent of eligible prescriptions 3. Enters electronic medication orders into the medical record for more than 30 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 prescribers to generic alternatives 6. Alerts prescribers to formulary status Documentation Factors 1-3: Reports showing percent of electronic prescriptions generated, transmitted and entered into medical record Factor 2 alternative: Prescribing process, report, explanation Factors 4-6: Reports or screen shots demonstrating the systems capabilities Scoring 5-6 factors (including factor 2) = 100% 4 factors= (including factor 2) = 75% 2-3 factors= (including factor 2) = 50% 1 factor = 25% 0 factors = 0% CRITICAL FACTOR = FACTOR 2 The practice uses an electronic prescription system with the following capabilities. 1. More than 50 percent of eligible prescriptions written by the practice are compared to drug formularies and electronically sent to pharmacies+ 2. Enters electronic medication orders into the medical record for more than 60 percent of patients with at least one medication in their medication list+ 3. Performs patient-specific checks for drug-drug and drug-allergy interactions+ 4. Alerts prescriber to generic alternatives + Stage 2 Core Meaningful Use Requirement Documentation Factors 1, 2 and 3: Report with a numerator and denominator Factor 4: Screen shot demonstrating functionality Scoring 4 factors = 100% 3 factors = 75% 2 factors = 50% 1 factor = 25% 0 factors = 0%
Key: Proposed Additions Proposed Deletions Recommendations Delete PCMH 2011 3E Factors 1-4, 6 and replace with PCSP 4C, Factors 1,3,4 and documentation to reflect Stage 2 Meaningful Use requirements. Renumber factor 5 (now 4).
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Use Proposed Requirement (Column 2) element names when participating in public comment. PCMH 3E: Support Self-Care and Shared Decision PCMH 4A: Support Self-Care Process Making The practice conducts activities to support The practice has and demonstrates use of materials patients/families in self-management: to support patients and families/caregivers in self1. Provides educational resources or refers at least management and shared decision making 50 percent of patients/families to educational resources to assist in self-management 1. Uses an EHR to identify patient-specific 2. Uses an EHR to identify patient-specific education education resources and provide them to more resources and provide them to more than 10 percent than 10 percent of patients+ of patients, if appropriate 2. Provides educational materials and resources 3. Develops and documents self-management plans 3. Provides self-management tools to record selfand goals in collaboration with at least 50 percent of care results patients/families 4. Adopts shared decision making aids 4. Documents self-management abilities for at least 5. Offers or refers to structured health education 50 percent of patients/families programs such as group classes and peer 5. Provides self-management tools to record self-care support results for at least 50 percent of patients/families 6. Maintains a current resource list on five topics or 6. Counsels at least 50 percent of patients/families to key community service areas of importance to adopt healthy behaviors the patient population including services offered outside the practice and its affiliates Documentation 7. Monitors frequency or feedback on usefulness of Factors 1-6: Report from electronic system or referrals to identified community resources submission of Record Review Workbook + Stage 2 Core Meaningful Use Requirement Scoring 5-6 factors (including Factor 3) = 100% Documentation 4 factors (including Factor 3) = 75% Factors 1,7: Report 3 factors (including Factor 3) = 50% Factors 2-6: Materials; demonstration of use might be 1-2 factors = 25% through tracking logs, process description, de0 factors = 0% identified patient record notes Scoring 5-6 factors = 100% 4 factors = 75% 3 factors = 50% 1-2 factors = 25% 0 factors = 0%
Key: Proposed Additions Proposed Deletions Delete current element 4A Include self management plan and barrier assessment in care planning element. Combine factors 1, 2, 5 from 4A and factors 1, 2, 4 from 4B into a new element under standard 3. Add new factor (4) to encourage the use of shared decision making tools to help guide collaborative discussion and decisions. Modified factor 7 to provide practice with greater flexibility in how they monitor value of community resources.
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Use Proposed Requirement (Column 2) element names when participating in public comment. Delete Element. Content Moved. PCMH 4B: Provide Referrals to Community Resources NOTE: Comments on this change should be offered The practice supports patients/families that need as a general response to standard 3 or in the element access to community resources: where content was moved. 1. Maintains a current resource list on five topics or key community service areas of importance to the patient population 2. Tracks referrals provided to patients/families 3. Arranges or provides treatment for mental health and substance abuse disorders 4. Offers opportunities for health education programs (such as group classes and peer support). Documentation Factor 1: List of community services or agencies Factor 2: Referral log or report covering at least one month Factors 3-4: Processes to provide/arrange for mental health/substance abuse treatment and health education support Scoring 4 factors = 100% 3 factors = 75% 2 factors = 50% 1 factor = 25% 0 factors = 0%
Key: Proposed Additions Proposed Deletions Delete element. Move factors 1, 2, and 4 to new element 3E. Delete factor 3 and add factors to 5B specifically requiring the practice to have an agreement with at least one behavioral health provider. This could be within the practice (co-located, integrated) or out in the community.
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement PCMH 4: Track and Coordinate Care PCMH 4A: Test Tracking and Follow-Up PCMH 5A: Test Tracking and Follow-Up The practice has a documented process for and demonstrates that it: 1. Tracks lab tests until results are available, flagging and following up on overdue results 2. Tracks imaging tests until results are available, flagging and following up on overdue results 3. Flags abnormal lab results, bringing them to the attention of the clinician 4. Flags abnormal imaging results, bringing them to the attention of the clinician 5. Notifies patients/families of normal and abnormal lab and imaging test results 6. Follows up with inpatient facilities on newborn hearing and blood-spot screening (NA for adults) 7. Electronically communicates with labs to order tests and retrieve results 8. Electronically communicates with facilities to order and retrieve imaging results 9. Electronically incorporates at least 40 percent of all clinical lab test results into structured fields in medical records 10. Electronically incorporates imaging test results into medical records. Documentation Factors 1-6: Process/procedure for staff and Factors 1- 2: Report, log or evidence of process use Report must include a minimum of 1 wk. of data or equivalent Factors 3- 6: Examples showing factors are met Factor 6: Provide a written explanation for NA Factors 7, 8,10: Process and examples from electronic system Factor 9: Report with numerator, denominator and percent; 12 mo. or 3 mo. if 12 mo. not available Scoring 8-10 factors (including Factors 1 and 2) = 100% 6-7 factors (including Factors 1 and 2) = 75%
Key: Proposed Additions Proposed Deletions Recommendations Replace PCMH 2011 5A Factors 7-10 with PCSP Factors 7-10 to reflect Stage 2 MU requirements.
The practice has a documented process for and demonstrates that it: 1. Tracks lab tests until results are available, flagging and following up on overdue results 2. Tracks imaging tests until results are available, flagging and following up on overdue results 3. Flags abnormal lab results, bringing them to the attention of the clinician 4. Flags abnormal imaging results, bringing them to the attention of the clinician 5. Notifies patients/families of normal and abnormal lab and imaging test results 6. Follows-up with inpatient facility on newborn hearing and newborn blood-spot screening (NA for adults) 7. More than 30 percent of laboratory orders are electronically recorded in the patient record+ 8. More than 30 percent of radiology orders are electronically recorded in the patient record+ 9. Electronically incorporates more than 55 percent of all clinical lab test results into structured fields in medical record+ 10. 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 Documentation Factors 1-6: Process/procedure for staff and Factors 1-2: Report, log or evidence of process use; report must include a minimum of 1 wk. of data or equivalent Factors 3-6: Examples showing factors are met Factor 6: Provide a written explanation for NA Factors 7, 8,10: Process and examples from electronic system Factor 9: Report with numerator, denominator and percent; 12 mo. or 3 mo. if 12 mo. not available Page 20 of 33
Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement 4-5 factors (including Factors 1 and 2) = 50% 3 factors (including Factors 1 and 2) = 25% Scoring Fewer than 3 factors = 0% 8-10 factors = 100% CRITICAL FACTORS= FACTORS 1 AND 2 6-7 factors = 75% 4-5 factors = 50% 3 factors = 25% Fewer than 3 factors = 0% CRITICAL FACTORS = FACTORS 1 AND 2 PCMH 4B: Referral Tracking and Follow-Up PCMH 5B: Referral Tracking and Follow-Up The practice coordinates referrals by: 1. Giving the consultant or specialist the clinical reason for the referral and pertinent clinical information 2. Tracking the status of referrals, including required timing for receiving a specialists report 3. Following up to obtain a specialists report 4. Establishing and documenting agreements with specialists in the medical record if co-management is needed 5. Asking patients/families about self-referrals and requesting reports from clinicians 6. Demonstrating the capability for electronic exchange of key clinical information (e.g., problem list, medication list, allergies, diagnostic test results) between clinicians 7. Providing an electronic summary of the care record to another provider for more than 50 percent of referrals Documentation Factor 1: Demonstrate process for important referrals showing reason and clinical information Factors 2-3: Report or log showing process for tracking, timing and follow up. Report must include a minimum of 1 wk. of data or equivalent Factors 4-5: Documented processes and three examples Factor 6: Screen shot showing capability Factor 7: Report with numerator, denominator and percent with 12 mo. or 3 mo. if 12 mo. not available
Replace the Stem to clarify expectations of the practice Add Factor 1: to align with the requirements in PCSP to emphasize the need for collaboration and coordination of care between primary care and specialty practices. Add new Factors 2 and 3: specifically requiring arrangements with behavioral health providers Add to Factor 3 (now 4): the urgency and type to ensure that both urgency and type of referral are included as important features of a referral request. Add to Factor 3 (now 5): pertinent demographic and clinical data, including test results. Add Factor 6: Giving the consultant or specialist the current care plan to emphasize the importance of communicating about and coordinating the care plan. We are also considering adding a factor that would encourage practices to participate in organized community activities to improve care coordination. We welcome comments on this concept.
The practice has a written process for implementing and managing referrals with specialists and monitors performance against the standards that includes: The practice coordinates referrals by: 1. Formal and informal agreements with a subset of specialists based on established criteria 2. Agreement(s) with behavioral health providers 3. Direct integration or co-location of behavioral health providers within the practice site 4. Giving the consultant or specialist the clinical question, the urgency and type of referral 5. Giving the consultant or specialist pertinent demographic and clinical data, including test results 6. Giving the consultant or specialist the current care plan 7. Tracking the status of the referrals, including required timing for receiving a specialists report 8. Following up to obtain specialists report 9. Establishing and documenting agreements with specialists in the medical record if co-management is needed 10. Asking patients/families about self-referrals and requesting reports from clinicians 11. Demonstrating capacity for electronic exchange of key clinical information+ 12. Providing an electronic summary of care record to another provider for more than 50 percent of referrals.+ 13. Considering available performance information on consultants/specialists when making referral recommendations
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement Scoring + Stage 2 Core Meaningful Use Requirement 5-7 factors = 100% 4 factors = 75% Documentation 3 factors = 50% Factors 1-13: Documented process and 1-2 factors = 25% Factors 1-10, 13: Report or log 0 factors = 0% Factor 12: Report with numerator, denominator and percent with 12 mo. or 3 mo. if 12 mo. not available Scoring 11-13 factors = 100% 8-10 factors = 75% 4-7 factors = 50% 2-3 factors = 25% 0-1 factors = 0% PCMH 4C: Coordinate Care Transitions On its own or in conjunction with an external organization, 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 4. Demonstrates its process for proactively contacting patients/families for appropriate follow-up care within an appropriate period following a hospital admission or emergency department visit 5. Demonstrates its process for exchanging patient information with the hospital during a patients hospitalization 6. Collaborates with the patient/family to develop/implement a written care plan for patients transitioning from pediatric care to adult care (NA for adult-only and family practices) 7. Demonstrate the process for obtaining proper consent for release of information (or protocols for doing so), as well as secure/timely information exchange and care coordination with community
PCMH 5C: Coordinate With Facilities and Care Transitions On its own or in conjunction with an external organization, the practice systematically: 1. Demonstrates its process for identifying patients with a hospital admission and or patients with an emergency department visit 2. Demonstrates its process for sharing clinical information with the admitting hospitals and or emergency departments 3. Demonstrates its process for consistently obtaining patient discharge summaries from the hospital and other facilities 4. Demonstrates its process for contacting patients/families for appropriate follow-up care within an appropriate period following a hospital admission or emergency department visit 5. Demonstrates its process for exchanging patient information with the hospital during a patients hospitalization 6. Collaborates with the patient/family to develop a written care plan for patients transitioning from pediatric care to adult care (NA for adult-only or family medicine practices) 7. Demonstrates the capability for electronic exchange of key clinical information with clinicians in facilities
Change Element title: Coordinate Care Transitions because the original title was redundant Change Stem: Delete "On its own or in conjunction with an external organization", to eliminate unnecessary wording. Modify Factor 6 to include expectations for the receiving adult care practice. Add a new factor (7) to address connections to community partners. Note that community partners includes schools for children.
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement partners 8. Provides an electronic summary-of-care record to another care facility for more than 50 percent of 8. Demonstrates the ability for electronic exchange of transitions of care. key clinical information with facilities 9. Provides an electronic summary-of-care record to Documentation another care facility for more than 50 percent of Factor 1: Documented process to identify patients transitions of care.+ and log or report Factors 2-5: Documented process and examples of + Stage 2 Core Meaningful Use Requirement providing clinical information, obtaining discharge summaries, follow up and exchange of information Documentation Factor 6: Example of a written transition care plan; Factor 1: Documented process to identify patients provide a written explanation for NA and log or report Factor 7: Screen shot showing test of capability Factors 2-5, 7: Documented process and examples Factor 8: Report with numerator, denominator and of providing clinical information, obtaining discharge percent summaries, follow up and exchange of information 12 months of transitions, or 3 months if 12 months Factor 6: Example of a written transition care plan; not available; provide a written explanation for NA provide a written explanation for NA Factor 8: Screen shot showing test of capability Scoring Factor 9: Report with numerator, denominator and 7-8 factors = 100% percent; 12 months of transitions, or 3 months if 12 5-6 factors = 75% months not available; provide a written explanation 3-4 factors = 50% for NA 1-2 factors = 25% 0 factors = 0% Scoring 7-8 factors = 100% 5-6 factors = 75% 3-4 factors = 50% 1-2 factors = 25% 0 factors = 0%
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Use Proposed Requirement (Column 2) element names when participating in public comment. Key: Proposed Additions Proposed Deletions Current Requirement Proposed Requirement Recommendations PCMH 5: Performance Measurement and Quality Improvement PCMH 5A: Measure Clinical Quality Performance PCMH 6A: Measure Performance Split into two elements (clinical quality and resource stewardship). Taken together with the element on The practice measures or receives data on the The practice measures or receives data on the measuring patient experience it will call attention to following: following: all parts of the triple aim. 1. At least three preventive care measures 2. At least three chronic or acute care clinical measures 3. At least two utilization measures affecting health care costs 4. Performance data stratified for vulnerable populations (to assess disparities in care). Documentation Factors 1-4: Reports showing performance Scoring 4 factors = 100% 2-3 factors = 75% No scoring option = 50% 1 factor = 25% 0 factors = 0% 1. At least two immunizations 2. At least two screening measures 3. At least three chronic or acute care clinical measures 4. Performance data stratified for vulnerable populations (to assess disparities in care). Documentation Factors 1-4: Reports showing performance Scoring 4 factors = 100% 3 factors = 75% 2 factors = 50% 1 factor = 25% 0 factors = 0% Explanation Factor 1: Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC). Factor 2: Screening may include services recommended by the U.S. Preventive Services Task Force (USPSTF), preventive care and screenings for children and for women as recommended by the Health Resources and Services Administration (HRSA) and other standardized preventive measures, including those identified in Bright Futures for pediatric patients. Examples of screening measures include: Cancer screening Developmental screening Immunizations Osteoporosis screening Colorectal cancer screening Depression screening (adults, teens, patients with
There is interest in requiring practices to either report on a common set of pre-defined measures or to demonstrate that they have selected the measures most relevant to their patient population. However, we have not reached agreement on how to make this a meaningful standard and not just a documentation exercise. We welcome any comments on this issue. Change Factor 1 from At least three preventive care measures to At least three rates of immunizations. Factors 1 and 2 are preventive care measures but are more specific and are aiming toward submitting to NCQA in the future for purposes of benchmarking. Add Factor 2: At least three screening measures. See Factor 1 above. Add to Factor 3: At least three chronic or acute care clinical measures (national measures). The goal is to strive for benchmarking and this is a mechanism for moving in that direction. Add Factor 4: Coordination of care results. This factor links to Element 5B with the practice systematically tracking receipt of referral reports from specialty practices and the primary care practice providing the specialty practice with test results that have already been performed to help avoid duplication of services. Include in the Explanation: Practice may choose from a suite of measures: DRP, HSRP, preventive (adult or pediatric), depression Screening measures may include: (smoking status, Page 24 of 33
Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement chronic conditions or comorbidities) Assessment of behaviors affecting health, such as smoking, BMI and alcohol use. Factor 3: Chronic or acute care clinical measures may be associated with important conditions identified by the practice (e.g., diabetes, heart disease, asthma, depression, chronic back pain, otitis media), based on evidence-based guidelines. Measures of overuse of potentially ineffective interventions, such as overuse of antibiotics for bronchitis, may also be used. Practices should consider using measures from national measure sets such as HEDIS, NCQA Recognition Programs or based on NQF-endorsed measure specifications. Practices where 75 percent or more of the clinicians currently hold recognition in the NCQA Heart/Stroke Recognition Program (HSRP), Diabetes Recognition Program (DRP) or Back Pain Recognition Program (BPRP) automatically receive credit for factor 3. The practice should include a statement about the recognized clinicians, the name of the recognition program and the number or percentage of recognized clinicians in the practice.
Key: Proposed Additions Proposed Deletions Recommendations alcohol use, BMI, depression in adults or teens or patients with chronic conditions or co-morbidities, ADHD, colorectal cancer, mammograms) Utilization measures affecting health care costs may include rates of ER visits, hospitalizations, follow-up post-hospitalization within a specified period of time)
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement NEW! PCMH 5B: Measure Resource Stewardship The practice measures or receives quantitative data on the following: 1. At least two measures related to care coordination 2. At least two utilization measures affecting health care costs Documentation Factors 1-2: Reports showing performance Scoring 2 factors = 100% No scoring option = 75% 1 factor = 50% No scoring option = 25% 0 factors = 0% Explanation Factor 1: The practice measures how well it tracks and coordinates care by monitoring quantitative data that captures a relevant process or outcome. Measures may be associated with tracking and referral activities in PCMH 5B. For example, frequency with which the practice provides a clear clinical reason for the referral.
Key: Proposed Additions Proposed Deletions Recommendations See recommendation directly above.
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement PCMH 5C: Measure Patient/Family Experience PCMH 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 and Whole-person care/self-management support 2. The practice uses the CAHPS Patient-Centered Medical Home (PCMH) survey tool 3. The practice obtains feedback on the experiences of vulnerable patient groups 4. The practice obtains feedback from patients/families through qualitative means Documentation Factors 1-4: Reports showing results of patient feedback Scoring 4 factors = 100% 3 factors = 75% 2 factors= 50% 1 factor = 25% 0 factors = 0% 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 Whole person care/self-management support 2. The practice uses the Patient-Centered Medical Home version of the CAHPS Clinician & Group Survey Tool 3. The practice obtains feedback on experiences of vulnerable patient groups 4. The practice obtains feedback from patients/families through qualitative means Documentation Factors 1-4: Reports showing results of patient feedback Scoring 4 factors = 100% 3 factors = 75% 2 factors= 50% 1 factor = 25% 0 factors = 0%
Key: Proposed Additions Proposed Deletions Recommendations No changes.
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement PCMH 5D: Implement Continuous Quality PCMH 6C: Implement Continuous Quality Improvement Improvement The practice uses an ongoing quality improvement process to: 1. Set goals and act to improve performance on at least three measures from Element A 2. Set goals and act to improve performance on at least one measure from Element B 3. Set goals and address at least one identified disparity in care or service for vulnerable populations 4. Involve patients/families in quality improvement teams or on the practices advisory council. Documentation Factors 1-3: Report or completed PCMH Quality Measurement and Improvement Worksheet Factor 4: Process demonstrating how it involves patients/families in QI teams or advisory council Scoring 3-4 factors = 100% No scoring option = 75% 2 factors = 50% 1 factor = 25% 0 factors = 0% The practice uses an ongoing quality improvement process to: 1. Set goals and analyze at least three clinical quality measures from Element A 2. Act to improve at least three clinical quality measures from Element A 3. Set goals and analyze at least one measure from Element B 4. Act to improve at least one measure from Element B 5. Set goals and analyze at least one patient experience measure from Element C 6. Act to improve quality on at least one patient experience measure from Element BC 7. Set goals and address at least one identified disparity in care/service for vulnerable populations identified in Element A or C 8. Involve patients/families/caregivers in quality improvement teams or on the practices advisory council. Documentation Factors 1-7: Report or completed PCMH Quality Measurement and Improvement Worksheet Factor 8: Process demonstrating how it involves patients/families in QI teams or advisory council Scoring 8 factors = 100% 5-7 factors = 75% 3-4 factors = 50% 1-2 factors = 25% 0 factors = 0%
Key: Proposed Additions Proposed Deletions Recommendations Modified element to increase the expectations of practices in the area of performance measurement and continuous quality improvement. The measures on which practices are expected to focus their QI efforts are from Elements A, B and C representing the triple aim.
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement PCMH 5E: Demonstrate Continuous Quality PCMH 6D: Demonstrate Continuous Quality Improvement Improvement The practice demonstrates ongoing monitoring of the effectiveness of its improvement process by: 1. Tracking results over time 2. Assessing the effect of its actions 3. Achieving improved performance on one measure 4. Achieving improved performance on a second measure Documentation Factors 1-4: Reports showing measures over time, recognition results or completed Quality Measurement and Improvement Worksheet Scoring 4 factors = 100% 3 factors = 75% 2 factors = 50% 1 factor = 25% 0 factors = 0% The practice demonstrates continuous quality improvement ongoing monitoring of the effectiveness of its improvement process by: 1. Tracking results over time 1. Measuring the effectiveness of the actions taken to improve the five measures selected in Element D Assessing the effect of its actions. 2. Achieving improved performance on at least two clinical quality measures one measure 3. Achieving improved performance on one utilization or care coordination measure 4. Achieving improved performance on at least one patient experience measure a second measure Documentation Factors 1-4: Reports showing measures over time, recognition results or completed Quality Measurement and Improvement Worksheet Scoring 4 factors = 100% 3 factors = 75% 2 factors = 50% 1 factor = 25% 0 factors = 0% Explanation Factor 2: Clinical quality measures may include measures related to immunizations, screening, acute or chronic conditions.
Key: Proposed Additions Proposed Deletions Recommendations Updated factors to align with the triple aim and to raise expectations to impact performance in all three dimensions to receive full credit. NCQA will provide further guidance regarding appropriate methodologies for measuring effectiveness (e.g., measurements should be at least one year apart and represent the same length of time) and what level of impact qualifies as an improvement. We welcome any other suggestions to make this standard more clearly about continuous quality improvement - where QI is an ongoing way of doing business rather than a project mentality.
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement PCMH 5F: Report Performance PCMH 6 E: 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. Documentation Factors 1, 2: Reports (blinded) showing summary data by clinician and across the practice shared with the practice and how the results are shared Factor 3: Example of reporting to patients or the public Scoring 3 factors = 100% 2 factors = 75% 1 factors = 50% No scoring option = 25% 0 factors = 0% The practice produces performance data reports using measures from Elements A, B and C and shares the following: both Element A and Element B. 1. Individual clinician results with the practice Within the practice, results by individual clinician 2. Practice-level results with the practice 3. Individual clinician or practice-level results publicly or to patients Documentation Factors 1, 2: Reports (blinded) showing summary data by clinician and across the practice shared with the practice and description of how the results are shared Factor 3: Example of reporting to patients or the public Scoring 3 factors = 100% 2 factors = 75% 1 factors = 50% No scoring option = 25% 0 factors = 0% The practice will be scored on the three factors three times - once for each of the measure domains (from elements A, B and C).
Key: Proposed Additions Proposed Deletions Recommendations Minor language changes to clarify expectations. Change scoring so that practice is encouraged to share measures from each of the three measurement domains (clinical quality, resource use and patient experience).
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement Delete content moved PCMH 6F: Report Data Externally The practice electronically reports: 1. Ambulatory clinical quality measures to CMS or states 2. Ambulatory clinical quality measures to other external entities 3. Data to immunization registries or systems 4. Syndromic surveillance data to public health agencies. NOTE: Comments on this change should be offered as a general response to standard 5 or in the element where content was moved (5G).
Key: Proposed Additions Proposed Deletions Recommendations Combine remaining meaningful use requirements related to EHR capabilities from 6F and 6G and update to reflect Stage 2 into a new element 5G.We anticipate that this element will not have points assigned
Documentation Factors 1 and 2: Reports (blinded) showing summary data by clinician and across the practice shared with the practice and how the results are shared Factor 3: Example of reporting to patients or the public Scoring 3 factors = 100% 2 factors = 75% 1 factors = 50% No scoring option = 25% 0 factors = 0% PCMH 6G: Use Certified EHR Technology This element is for your practice site Meaningful Use report only and will NOT be scored for your PCMH Recognition decision. To meet the federal Core and Menu Meaningful Use requirements: 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
PCMH 5G: Use Certified EHR Technology The practice uses a certified EHR system 1. The practice uses an EHR system (or modules) that has been certified and issued a CMS certification ID+ 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++ 4. The practice demonstrates capability to identify and report cancer cases to a public health central
Combine remaining meaningful use requirements related to EHR capabilities from 6F and 6G and update to reflect Stage 2. We anticipate that this element will not have points assigned.
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement deficiencies cancer registry electronically++ 5. The practice demonstrates capability to identify Documentation and report specific cases to a specialized registry Factor 1: CHPL Number(s) entered in survey tool text electronically (other than a cancer registry)++ box 6. The practice reports clinical quality measures to Factor 2: Entering yes in the survey tool is Medicare or Medicaid agency as required for attestation to the appropriate security analysis and Meaningful Use.+++ updates 7. The practice demonstrates the capability to submit electronic data to immunization registries or Scoring immunization information systems.+ Not scored + Stage 2 Core Meaningful Use Requirement ++ Stage 2 Menu Meaningful Use Requirement +++ CMS Meaningful Use Requirement This element is for data collection purposes only and will not be scored. Note: Factor 1 requires comments. 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+ Documentation Factor 1: CHPL Number(s) entered in survey tool text box By entering a yes response in the PCMH survey tool, the practice attests to its: using a Certified Electronic Health Record and has been issued a CMS certification ID to perform the designated CMS Meaningful Use Core and Menu requirements. Factor 2: By entering a yes response in the PCMH survey tool, the practice attests to: conducting the required security risk analysis of its certified EHR system (or modules) and implementing security updates as necessary and correcting identified
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Use Proposed Requirement (Column 2) element names when participating in public comment. Current Requirement Proposed Requirement security deficiencies. Entering yes in the survey tool is attestation to the appropriate security analysis and updates Factor 3: By entering a yes response in the PCMH survey tool, the practice attests to its: capability to submit electronic syndromic surveillance data to public health agencies and actual submission according to applicable law and practice. Factor 4: By entering a yes response in the PCMH survey tool, the practice attests to its: capability to identify and report cancer cases to a public health central cancer registry, except where prohibited, and in accordance with applicable law and practice. Factor 5: By entering a yes response in the PCMH survey tool, the practice attests to its: capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited and in accordance with applicable law and practice. Factor 6: By entering a yes response in the PCMH survey tool, the practice attests it reports clinical quality measures to Medicare or Medicaid as required for Meaningful Use and provides a copy of a report from the agency. Factor 7: By entering a yes response in the PCMH survey tool, the practice attests to its capability to submit electronic data to immunization registries or immunization information systems. Scoring Not scored
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PCMH Proposed 2014 Standards

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PCMH Proposed 2014 Standards

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