NPAIHB Regional
Extension Center
MU Performance Measures
Tip Sheet
Core Measures
You must meet them all for MU
There are 15
Computerized Provider Order Entry (CPOE) for Medication Orders:
>30% of all unique patients with at least one medication in their medication list seen by the
EP during the EHR reporting period have at least one medication order entered using CPOE.
o
o
o
o
o
o
This will likely be taken care of by your normal practices, just taking care of patients and
having the EP enter their medication orders in EHR
The logic is looking for medication with an Issue Date during the reporting period
It also looks for the Nature of Order. It does not count if Nature of Order = Written.
It counts for holders of the ORES key. It will count for holders of the ORELSE key if they
correctly enter the order under the EP’s name. Policy orders are a bit of a gray area –
stay tuned for clarification in MU Stage 2.
The EP is excluded if they write less than 100 prescriptions in the reporting period
If you do not have an onsite RPMS pharmacy, you can still meet this one (but that
doesn’t much matter because you can’t meet the e-Prescribing one – and both
measures are required)
Drug Interaction Checks:
The EP has enabled this functionality for the entire EHR reporting period.
o
o
o
o
o
o
You just answer Yes or No for this
This is all about getting your Clean Date set.
The Clean Date must be set prior to the start of your reporting period
It is a one-time thing – once your Clean Date is set, you do not have to do it again
Instructions on setting your Clean Date are on pages 20-35 of this document
http://www.ihs.gov/meaningfuluse/pdf/MU_Guide_EP_11.pdf
One way to check if your clean date is set is to do ^MUCD. If a date is shown, you’re set.
These next 3 measures are all very similar.
They are actually very straightforward and easy to meet and do not require that you
document reviewing the lists at every visit, though that may be part of good clinical practice
and is encouraged.
Maintain Problem List:
>80% of all unique patients seen by the EP during the EHR reporting period have an active problem
on their Problem List or an indication of no active problems recorded as structured data.
o
o
This will likely be taken care of by routine clinical practice.
Note it does not say you have to document that you reviewed the problem list at each
visit (that may be good clinical practice, but it is not required to meet this measure
 If there is an active problem on a patient’s problem list that is not updated in
any way during the reporting period, that meets the objective
 If a problem is added or deleted or otherwise updated during the reporting
period, that meets the objective
 If the patient truly has no active problems, this is when you use the review
button (or right click on the Problem List component) and select “No Active
Problems” to get credit for maintaining that patient’s problem list
Active Medication List:
>80% of all unique patients seen by the EP during the EHR reporting period have at least one
entry (or an indication that the patient has no active medications) recorded as structured
data.
o
o
o
This will likely be taken care of by routine clinical practice.
Note it does not say you have to document that you reviewed the medication list at
each visit (that may be good clinical practice, but it is not required to meet this
measure)
The logic is only looking at a combination of the issue date and the discontinue date (if
there is one). Here are some scenarios:
 If there is an active medication on the patient’s list that is not refilled during the
reporting period - that is fine, it still counts
 If a medication was active, but expires during the reporting period – that is fine,
it still counts
 If a medication is active during the reporting period, but is discontinued before
the end of the reporting period – that is fine, it still counts
 If a new medication is ordered during the reporting period, it counts - regardless
of where, or if it is filled
 If there is a medication in the Outside Medications component documented as
active, it counts
o
If the patient truly has no active medications, this is when you use the review button (or
right click on the Medication List component) and select “No Active Medications” to get
credit for maintaining that patient’s medication list
Medication Allergy List:
>80% of all unique patients seen by the EP during the EHR reporting period have at least one
entry (or an indication that the patient has no known medication allergies) recorded as
structured data.
o
o
o
o
o
o
This will likely be taken care of by routine clinical practice.
Note it does not say you have to document that you reviewed the allergy list at each
visit (that may be good clinical practice, but it is not required to meet this measure)
If there is an active allergy listed in the patient’s list in the Adverse Reaction Tracking
package and is not updated in any way during the reporting period – that is fine, it
counts
If the patient has no known allergies, and that is already documented in the ART
package – that is fine, it counts
If the patient has no known allergies, and that is not already documented in the ART
package, this is when you Right click on the Allergies/Adverse Reactions List component)
and choose “New Adverse Reaction” and then click the “No Known Allergies” box at the
bottom of the dialog that appears to get credit for that patient for this measure.
 The allergy chart review button does not play a direct role in meeting this
measure - though as stated before, can be part of good clinical practice
Note: an allergy listed on the patient’s Problem List alone will not count for this measure
– the reaction must be documented in the Adverse Reaction Tracking package.
Periodically running the PLAL list to identify allergies on problem lists is part of a good
maintenance routine for your ART Package.
e-Prescribing (eRx):
>40% of all permissible prescriptions written by the EP during the EHR reporting period are
transmitted electronically using certified EHR technology.
o
o
o
o
An EP is excluded if they write < 100 prescriptions during the reporting period
For RPMS EHR, if you write medications in EHR and they are filled at an on-site RPMS
Pharmacy, you can meet this measure
Controlled Substances and medications marked as “Administered in Clinic” are excluded
If you do not use an RPMS Pharmacy, you will need the RPMS e-Prescribing package
(BPER)
 This allows you to send prescriptions directly from RPMS EHR to an outside
pharmacy or an onsite COTS pharmacy
 This was officially released in March 2012 as a controlled roll out
 There are many prerequisites to going live on e-Prescribing
 To get more information, contact Katie or Neill
Record Demographics:
>50% of all unique patients seen by the EP during the EHR reporting period have all
demographics recorded as structured data.
o
o
o
There are 5 items the logic is looking for: Preferred language, Race, Ethnicity, Sex, and
Date of Birth. It is simply looking for the presence of something in each of these fields in
Patient Registration package during the reporting period
Mark these as mandatory in the Patient Registration Package
Any one of these items that is missing will count against you in this measure
Record Vital Signs:
>50% of all unique patients age two years or older seen by the EP during the EHR reporting period
have height, weight, and blood pressure recorded as structured data.
o
o
o
o
Use EHR Vitals entry to enter height, weight, and blood pressure
The logic looks for the presence of data in these 3 fields during the reporting period
It is not required that you enter these vitals at every visit, though it may be good clinical
practice
It does not matter who enters the vitals – may be MA or nurse or doc or pharmacist, etc
Record Smoking Status:
>50% of all unique patients 13+ years or older seen by the EP during the EHR reporting period
have smoking status recorded as structured data.
o
o
o
o
Use the Tobacco (Smoking) health factor to document smoking status in EHR
The logic is looking specifically for the presence of one of these health factors in the
reporting period
 Current smoker, every day
 Current smoker, some day
 Current smoker, status unknown
 Previous (former) smoker
 Never smoked
 Smoking status unknown
It is not necessary to document it at every visit
Reminders and Reminder Dialogs can be very handing both in helping you to know when
to screen patients and in documenting the health factor
Clinical Quality Measures (CQM):
Successfully report Clinical Quality Measures to CMS or appropriate state Medicaid.
o
o
o
o
There are no targets to meet for these measures, but you do have to report on them
In order to do that, you need to run the EP Clinical Quality Measure Report from CRS for
your reporting period
Save the report, you will have to enter these numbers in either your state’s attestation
website (if Medicaid) or CMS’s website (if Medicare) at the time of attestation
When running the report, choose the Selected Measures (User Defined) report
o
o
o
Choose three core or alternate core measures (marked with (C) and (A)) and three menu
set measures (marked with (M)).
You must choose three core or alternate core measures that do not have a
denominator=0.
(If any of the menu set measures have denominator=0, you must select other measures
that do not have denominator=0.)
Clinical Decision Support Rule:
Implement one clinical decision support rule during EHR reporting period.
o
o
o
This is just a Y/N question asking if you implemented this
There are any number of items in EHR you could use to do this
The MU Performance Measure report will look at your RPMS system for you and will
automatically answer Y to this question if you have any of the following things
configured on your system:
 Clinical Reminders installed and national reminders configured
-OR On the EHR Reports tab: Diabetes, Pre-Diabetes, Asthma, Anti- coagulation, or
Women's Health Supplement; Immunization Package Forecasting; and/or Health
Maintenance Reminders.
Electronic Copy of Health Information:
>50% of all patients of the EP who request an electronic copy of their health information during the
EHR reporting period are provided it within three business days.
o
o
o
A couple things to note here –
 The logic is looking for “electronic” as the Patient/Agent Request Type and the
Record Dissemination fields in the Release of Information Package in RPMS. (If
you are not using the ROI package to track requests for ROI, then you will need
to track and calculate this measure in another way and have that be very clear
in the event of an audit)
 An EP is excluded if there are no requests from a patient for electronic copies of
their health information
If a patient does request an electronic copy of some health information, you will need to
have a policy and procedure in place as to how that information can be supplied and
how it will be encrypted. IE, on a thumb drive or CD, will the patient provide the
electronic device, etc. You will also want to address that when the data is encrypted, a
password will be required. You will need to address how password management will be
handled, including what to do if the patient forgets the password.
If a patient requests an electronic copy of health information and you can’t provide it to
them within 3 days, you also need to document that in the ROI package.
Clinical Summaries:
Clinical summaries provided to patients for >50% of all office visits within three business
days.
o
o
o
This is a measure that is often confused with other measures
This one is met by providing the patient with a Patient Wellness Handout containing at
least these 4 items: (1) medication list; (2) allergy list; (3) problem list; and (4) lab
results.
 Demographics are also required, but are hard coded as part of the PWH, so
nothing to worry about there
 There may be additional items on here if you choose
 It does not matter who prints the PWH
 It can’t be printed before the patient checks in for that day – but you do have a
window:
 It must be printed on or after the visit date/time but within 3 business days of
the visit
 It is perfectly fine to have more than one PWH configured for you system and to
generate more than one throughout the course of the patient’s visit
*Printing a PWH as part of your clinic routine can help you easily meet one of the Menu
Set objectives called Patient Reminders – see below
Electronic Exchange of Clinical Information:
Performed at least one test of certified EHR technology's capacity to electronically exchange
key clinical information.
o
o
o
o
o
This is the measure about the C32
You do not need D1 access to make this work.
 You should be able to generate, view, save, print, etc a C32 document from your
own EHR.
 The only trouble with D1 may be the transmission of the C32 to the URL in
Albuquerque. That is fine for this stage of MU. Eventually, you will be able to
pull C32 documents from other sites within IHS and even outside of IHS (local
hospital, private doc’s office, etc) and view in your EHR, but this part of the
Health Information Exchange is not up and running yet and it is unclear how the
D1 issue will be addressed for IHS as a whole. Stay tuned, but don’t worry about
it for now.
The C32 application is installed as part of your certified EHR, however, there is some
significant set up that needs to be done in order for the C32 button to function within
your EHR
Your site manager and Area Site Analyst will need to help you get the background set up
and the CAC can place the C32 button in the EHR
To meet the MU measure, you actually only have to perform one test of C32
transmission by following these instructions:
http://www.ihs.gov/meaningfuluse/pdf/ProcessTestingC32ForMUreqs.pdf

o
Step 2 is “Contact the Help Desk and receive the URL of the C32 repository that
you will be sending C32s to.” The Help Desk in this case is your Portland Area
Site Analyst – they will provide this URL to you
 The test can fail, but it must be completed and documented (via screen shot) at
some point prior to the end of the reporting period.
 The test can be done before the reporting period starts, but it will have to be
done for each participation year (once for 2011, once for 2012, etc). Since our
EPs are using the same EHR in the same location, just one test for the whole
facility is sufficient. You may want to put a copy of the screen shot in each EP’s
folder.
See C32 Appendix to this document with some more information
Protect Electronic Health Information:
Conducted or reviewed a security risk analysis of the certified EHR, implemented security
updates as necessary and corrected identified security deficiencies as part of risk
management process.
o
o
o
o
o
You need to conduct a security risk analysis sometime before the end of your reporting
period and review it sometime during your reporting period
A template developed by OIT is available for this:
http://www.ihs.gov/meaningfuluse/index.cfm?module=toolkit
You need to fill out the template and make efforts to correct deficiencies that are found
Ensure a sanction policy is adopted (required for federal sites; tribal/urban sites may
elect to adopt IHS policy). If your site adopts sections from Part 8 of the IHS Manual, in
whole or in part and IHS SOPs and appropriate SGMS, this will meet the requirements of
adopting a sanction policy
You can contact Doug Bristow at Portland Area Office with questions about the Security
Risk Analysis document:
 Dougls.bristow@ihs.gov Phone # (503) 414-7753
Menu Set Measures
There are 10
You must choose 5
Drug-Formulary Checks:
The EP has enabled this functionality and has access to at least
one internal or external formulary for the entire EHR reporting period.
o
o
o
This can be an easy one to meet if you have a formulary (even if you don’t have a
pharmacy onsite)
To meet this, you have to have your Clean Date set (see above)
Then, utilize the field in the drug file to mark drugs as Non-Formulary as appropriate for
your site. When the provider enters and order in EHR for a drug marked in this way, a
o
Non Formulary message will appear. That meets this measure. (As a side note, you
may also want to populate the formulary alternatives field in the drug file as a handy
tool for your providers)
You just answer Y/N for this measure.
Clinical Lab Test Results:
>40% of all clinical lab results ordered by EP during EHR reporting period whose results are
either in a positive/negative or numerical format are incorporated in the certified EHR as
structured data.
o
o
o
If you are using the RPMS lab package and have a bi-directional reference lab interface
running, this should be an easy measure to meet
Having the POC lab button set up and utilized correctly will help you meet this measure
as well
If you do not have the interface or do not have onsite lab, you may not want to choose
this measure.
Patient Lists:
Generate at least one report listing the EP’s patients with a specific condition during the EHR
reporting period.
o
o
This is another easy one to meet
You can run any number of reports from RPMS or iCare – including reports from the
Women’s Health Package, the Diabetes Audit, the Immunization package, CRS, and
QMAN and VGEN reports
Patient Reminders:
>20% of all unique patients who are 0-5 or 65+ years for whom a PWH was printed during the
EHR reporting period.
o
o
o
o
o
o
This one is not about the Clinical Reminders package in EHR – it is about reminding the
patient that they are due for some screening or care
Much like the Clinical Summaries Core measure discussed above, the logic is just looking
to see if a PWH was printed for these patients.
Include the Immunization Due or Cancer Screening components on your PWH and that
will meet this measure when it is printed for the patient.
You can include one (or both) of these items on the PWH that you use for the Clinical
Summaries measure and meet this measure at the same time when you print the PWH
Or, you can have different PWH for different scenarios – whatever fits your clinic
workflow the best – what meets these two measures is simply printing a PWH for the
patient.
This is looking at the entire patient population, not patients who had visits
necessarily…so having lots of inactive patients whose records have not been inactivated
could affect this measure – just something to be aware of.
o
Another suggestion that if you are sending out appointment letters or immunization
letters, just print the PWH and send it with these letters. This will increase your
numbers and help you catch additional patients for this measure.
Patient Electronic Access: At least 10% of all unique patients seen by the EP during the EHR
reporting period are provided timely (available within four business days) electronic access to
their health information.
o
o
Don’t choose this one
This is the Personal Health Record (PHR) and is not yet ready to roll for anyone in IHS
Patient Specific Education Resources: >10% of all unique patients seen by the EP during the
EHR reporting period are provided patient- specific education resources.
o
o
o
o
o
o
This should be another easy one.
The logic is looking for an education code with Literature as the subtopic (so anything
with the “–L” in the code)
It is looking for a code on a visit with the eligible provider any time during the reporting
period, so you do not have to do this at every visit
Using the “I” button in EHR can make this easier…you can connect to a patient
education site, print off materials, give it to the patient, and documents the xx–L
education code in the dialog that launches automatically in EHR
Or, you can document the xx-L code any other way…via an education pick list, superbill
association or straight on the education component, etc.
There is no specification on what literature you provide the patient or where you get it,
or on who documents the education code, just that it gets done
Medication Reconciliation:
Perform medication reconciliation for >50% of transitions of care in which the patient is
transitioned into the care of the EP.
o
o
o
o
Medication Reconciliation can mean many different things to different people in
different contexts.
For this MU menu measure, it is looking for the documentation of the M-MR
(Medication – Medication Reconciliation) education code on the EP’s visit for that day.
It does not matter who documents the M-MR education code
The PWH is not required for this measure, but may be part of a good clinical workflow
for medication reconciliation
Transition of Care Summary:
EP who transitions or refers their patient to another care setting/provider provides a
summary of care record for >50% of transitions of care/referrals.
o
o
This is met by using the RCIS tab and C32 button on that tab in EHR
If you are not using the RCIS tab yet, then don’t choose this measure (It is not require
that you use RCIS to meet MU since this is a Menu set measure)
o
o
If you are using the RCIS tab, make sure the C32 button is working on that tab (if the C32
button is working elsewhere in your EHR, there should not be any additional set up to
make it work. One of the recent patches may have “broken” the button – contact Katie
or Neill if yours is not working) and use it to print a C32 for each referral on the RCIS tab
to meet this measure. This can be done within 14 days of the initial referral date.
There is also a report in RPMS that can assist you – Active Referrals without a Printed
C32
These next 2 measures are known as the Public Health measures. You can choose
either one, but you do have to choose one of them. The exception here is the Oregon
Medicaid program, they chose to make the Immunization one mandatory.
Immunization Registries Data Submission:
Performed at least one test of certified EHR’s capacity to submit electronic data to
immunization registries and follow- up submission if the test is successful.
o
o
Check with your immunizations coordinator. If you are successfully exchanging data
with the state, you meet this measure. You can use one of your confirmation messages
as documentation and simply answer Yes to this measure (no % thresholds to meet
here)
For providers doing the Oregon Medicaid program, you must choose this measure.
 RPMS developers are working on being able to exchange with Oregon, but there
are currently some problems. You can still meet this measure by generating a
test message and sending it to Oregon’s system (ALERT). Generate the message
using BYIM Test and send it to the ALERT website (you have to have a user
account there). Save a screen shot of the results of the test.
Syndromic Surveillance Data Submission:
Performed at least one test of certified EHR’s capacity to provide electronic syndromic
surveillance data to public health agencies and follow- up submission if the test is successful.
o
o
o
This is met by the RPMS ILI/H1N1 Surveillance Export to the IHS Division of Epidemiology
and Disease Prevention.
If you want to choose this measure, check that this export is set up
Ensure data is being sent by setting up an e-mail export file receipt notification. If
notifications cease, contact your site manager to restart the exports. Saving a copy of
one of the email receipts will serve as your documentation that this measure was met
C32 Appendix:



The server that the C32 software is located on requires a minimum of 16GB of RAM for the C32
to function properly, otherwise the EHR will hang/crash
C32 will not work if the firewall is turned on
C32 Folder Permissions:
o When C32 is enabled in EHR and first launched, it will create a folder called “C32” on the
C:\ Drive
o EHR requires Write/Modify Permissions to this folder; by default, normal users do not
have these permissions
o In order to give write/modify permissions to the folder for all users, administrators that
have write/modify permissions must run the PowerShell Script that is listed below
o Facilities should contact and work with their Area IT Analyst when they are ready to go
forward with C32 implementation
Powershell Script to give permissions to each user:
The only part you need to change is CHANGE THIS TO YOUR SCRIPT PATH
Example:
If it is in a network location type “\\servername\deploy\scripts\
If f it is local type the C:\scripts\
Leave the PCs.txt on the end of it. Once you do this take and copy this text from the $ all the way to the
} and paste it into notepad. Save the file as a C32.ps1
$PCs = gc “CHANGE THIS TO YOUR SCRIPT PATH\PCs.txt"
foreach ($PC in $PCs){
$folderpath = "\\$PC\c$\C32"
$Acl = Get-Acl $folderpath
$Ar = New-Object system.security.accesscontrol.filesystemaccessrule("Authenticated
Users","FullControl","ContainerInherit, ObjectInherit","None","Allow")
$Acl.SetAccessRule($Ar)
Set-Acl $folderpath $Acl
}
Place the file in the directory you specified above.