How to Obtain NCQA Recognition as A Patient Centered Medical

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Donald T. Stewart, MDSammamish Diabetes and Lipid Clinic

DonS@SDALC.org

My Patient Centered Medical Home: Sammamish Diabetes and Lipid Clinic

in Sammamish Washington

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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?

PayorsBuyers Providers

Business

Medicare

Medicaid

Insurance Companies

Medicare Intermediaries

State Medicaid Organizations

Physicians

Hospitals

Nursing Homes

Home Health Providers

Patient Centered Primary Care Collaborative (PCPCC)

1. Employers - 50 Million Plus2. Consumer Groups - 47 Million Plus3. Physician Groups - 330,000 Plus4. Insurers – All of the Big Six

AARPAetna*American Academy of Family Physicians*American Academy of Pediatrics*American Board of Medical SpecialtiesAmerican College of Osteopathic Family PhysiciansAmerican Board of Medical SpecialtiesAmerican College of CardiologyAmerican College of Osteopathic InternistsAmerican College of Physicians*American Geriatrics SocietyAmerican Health Quality AssociationAmerican Heart AssociationAmerican Osteopathic Association*Aurum DxAutomotive Industry Action GroupBlueCross BlueShield Association*Bridges To ExcellenceThe Capital District Physicians’ HealthPlan, Inc.Carena, Inc.CaterpillarThe Center for Excellence in Primary CareThe Center for Health Value InnovationColorado Center for Chronic Care InnovationsCIGNA*CVS Caremark*§ CVS/pharmacy § Caremark Pharmacy Services § MinuteClinicDelmarva FoundationThe Department for Family and Community Medicine, University of California, San FranciscoDelphi CorporationDeseret MutualDMAA: The Care Continuum AllianceeHealth InitiativeThe ERISA Industry Committee*Exelon CorpFedEx CorporationFoundation for Informed Medical Decision MakingGeneral Mills, Inc.General Motors

Geisinger Health SystemsGlaxoSmithKlineHealth DialogHR Policy AssociationHumana, Inc.*IBM*Incenter StrategiesMcKesson CorporationMDdatacoreMedco*Medical Network OneMerck*MVP Health CareNational Association of Community Health CentersNational Business Group on HealthNational Business Coalition on HealthNational Coalition on Health CareNational Committee for Quality AssuranceNational Consumers LeagueNational Partnership for Women & FamiliesNational Retail FederationNew England Quality Care AllianceNew York City Department of Health and Mental Hygiene Novo NordiskThe Pacific Business Group on Health Partners In CarePfizer*Practice Transformation InstitutePudget Sound Health AllianceThe Roger C. Lipitz Center for Integrated Health Care at the Johns Hopkins Bloomberg School of Public HealthService Employees International UnionSociety of General Internal MedicineSociety of Teachers of Family MedicineThe Stoeckle Center at Massachusetts General Hospital UnitedHealthcare*United States SteelUniversity of Pittsburgh Medical Center Walgreens Health Initiatives*WellPoint, Inc.* WyethXerox

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 patient-centered 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 Recognition1. Download Application packet (and study it)

a) Dense 84 page Standards and Guidelines PDFb) 21 page agreement and attestation PDFc) 3 more documents totaling 11 pagesd) 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 care2. Coordinating visits with multiple clinicians and/or diagnostic tests

during one trip3. Determining through triage how soon a patient needs to be seen4. Maintaining the capacity to schedule patients the same day they call5. Scheduling same-day appointments based on practice’s triage of

patients’ conditions6. 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 time8. Providing urgent phone response within a specified time, with

clinician support available 24 hours a day, 7 days a week9. Providing secure e-mail consultations with the physician or other

clinician on clinical issues, answering within a specified time10. Providing an interactive practice Web site11. Making language services available for patients with limited English

proficiency12. 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%:written policies for 9 – 12 items– 75%: written policies for 7 – 8 items– 50%: written policies for 4 – 6 items– 25%: written policies for 2 – 3 items

1 A: Examples of Policies1. Patients schedule themselves online 24/7, and continuity of care is

guaranteed because there is only one provider2. Dr. Stewart provides all patient care and does all diagnostic tests at

the office, so care is coordinated at all times3. 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 week9. 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 communications11. 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 patient2. Appointments scheduled to meet the standards in 1A3. Response times to meet standards for timely response to

telephone requests4. Response times to meet standards for timely response to e-

mail and interactive Web requests5. 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%:Data supports 5 items– 75%: Data supports 4 items– 50%: Data supports 3 items– 25%: 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% 12 – 18 items documented for 75%– 75% 8 – 11 items documented for 75%– 50% 6 – 7 items documented for 75%– 25% 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 pressure4. 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 directives11. 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%-100% have at least seven fields– 75%: 50%-74% have at least seven fields– 50%: 25%-49% have at least seven fields– 25%: 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 lists2. Lists of over-the-counter medications, supplements and

alternative therapies3. Lists of prescribed medications, including both long-term and

short-term medications4. Structured template for age-appropriate risk factors (at least

3)5. Structured templates for narrative progress notes6. Age-appropriate standardized screening tool for

developmental testing7. 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%-100% of patients have 3 of 2D items– 75%: 50%-75% of patients have 3 of 2D items– 50%: 25%-49% of patients have 3 of 2D items– 25%: 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 diagnoses2.Most important risk factors in the practice’s

patient population3.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

04/21/23 52Sammamish Diabetes and Lipid Clinic, PLLC

04/21/23 53Sammamish Diabetes and Lipid Clinic, PLLC

Standard 3: Systematic Care Management

• 3A: The practice adopts and implements evidence-based diagnosis and treatment guidelines for (Must Pass):1. First clinically important condition2. Second clinically important condition3. 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 tests2. 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 in-person 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%:reminders for 4 items– 75%: reminders for 3 items– 50%: reminders for 2 items– 25%: 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 plans3. Writing individualized treatment goals 4. Assessing patient progress toward goals 5. Reviewing medication lists with patients6. 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% of patients have 4 items documented– 75%: 50%-74% have 4 items documented– 50%: 25%-49% have 4 items documented– 25%: 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 facilities2. Systematically sends clinical information to the

facilities with patients as soon as possible3. 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 Self-Management Support

• 4A: The practice assesses patient/family-specific barriers to communication using a systematic process to: 1. Identify and display in the record the language

preference of the patient and family2. 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 self-management support programs

5. Provides or connects patients/families to classes taught by qualified instructors

6. Provides or connects patients/families to other self-management 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%-100% have 3 activities documented– 75%: 50%-74% have 3 activities documented– 50%: 25%-49% have 3 activities documented– 25%: 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. Drug-drug interactions based on general information 2. Drug-drug interactions specific to drugs the patient takes 3. Drug-disease interactions based on general information 4. Drug-disease interactions specific to diseases the patient has 5. Drug-allergy alerts based on general information 6. Drug-allergy alerts specific to the patient 7. Drug-patient history alerts based on general information 8. Appropriate dosing based on general information 9. 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

1. Patient-appropriate medication information

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%:8 or more alerts/information used– 75%: 4 – 7 alerts/information used– 50%: 2 – 3 alerts/information used– 25%: 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 payor-

specific 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 results5. Follows up with inpatient facility on hearing screening and

metabolic screening to get results6. 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. Order lab tests2. Order imaging tests3. Retrieve lab results directly from source4. Retrieve imaging text reports directly from source5. Retrieve images directly from the source6. Route and manage current and historical test results to

appropriate clinical personnel for review, filtering and comparison

7. Flag duplicate tests ordered8. 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. Origination2. Clinical details

• Reason for the consultation • Pertinent clinical findings • Support person • Functional status • Family history • Social history • Plan of care • Health care providers

• 21. Receipt of consultant’s report

– 3. – 4. Administrative details– Insurance information, including whether the referral requires health plan approval

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 self-

care 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 practice2. 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. Request appointments by reviewing clinicians schedules2. Request referrals3. Request test results4. Request prescription refills5. See elements of their medical record6. 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 e-mail.

• 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. Patients needing clinical review or action2. Patients on a particular medication3. Patients needing preventive care4. Patients needing specific tests5. Patients needing follow-up visits6. 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 high-performing 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?