How to Obtain NCQA Recognition as A Patient Centered Medical Home Donald T. Stewart, MD Sammamish Diabetes and Lipid Clinic DonS@SDALC.org 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 3/23/2016 Sammamish Diabetes and Lipid Clinic, PLLC 52 3/23/2016 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?