2017 - Competency QI-A

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Table of Contents

<< Move to CC-C

>> Move to QI-B

Competency A: The practice measures to understand current performance and to identify opportunities for improvement

QI 01 (Core): Monitors at least five clinical quality measures across the four categories (must monitor at least one measure of each type):

A. Immunization measures.

The Dashboard includes data for the following immunization measures:

  • Immunization Rates - Adolescents (HPV, TdaP, and Meningococcal combined)
  • Immunization Rates - HPV
  • Immunization Rates - Influenza
  • Immunization Rates - Meningococcal
  • Immunization Rates - Patients 2 Years Old
  • Immunization Rates - Tdap

Data is updated monthly, and trend data is also reported.

B. Other preventive care measures.

Description Example/Screenshot/Documentation Source Date Added
Using Dashboard you can generate measure data for preventive measures including:
  • Well Visit Rates (for various age ranges)
  • Developmental Screening Rates for Infants
  • Fluoride Varnish Rate
Using "Patient List" and "Preventive Care Recall" tools within the EHR Report Library, you can now generate measure data for other preventive measures such as:
  • Preschool vision screening
  • Preschool hearing screening
  • Tobacco or alcohol abuse counseling for adolescents

C. Chronic or acute care clinical measures.

Description Example/Screenshot/Documentation Source Date Added
Using CQM reports in PCC EHR, you can generate measure data for chronic or acute care clinical measures including:
  • Use of Appropriate Medications for Asthma
  • Appropriate Testing for Children With Pharyngitis
  • Appropriate Treatment for Children With Upper Respiratory Infection (URI)
  • Followup Care for Children Prescribed ADHD Medication
How to Chart for each CQM in PCC EHR PCC 11/19/18
Using PCC EHR Report Library Reports Chronic Condition Recall and Patients Overdue for Weight Management, you can generate measure data for:
  • Obesity patient followup
  • Patients seen at the office within a week of ER or hospital discharge

D. Behavioral health measures.

Description Example/Screenshot/Documentation Source Date Added
Using Dashboard you can generate measure data for behavioral health measures including:
  • ADHD Patient Followup
  • Depression Screening Rates - Adolescents
Using Dashboard you can generate measure data for behavioral health measures including:
  • ADHD Patient Followup
  • Depression Screening Rates - Adolescents
Using PCC EHR Report Library Reports Patient List or Preventive Care Recall, you can generate measure data for:
  • Patients in need of maternal depression screening

QI 02 (Core): Monitors at least two measures of resource stewardship (must monitor at least 1 measure of each type):

A. Measures related to care coordination.

  • As it is related to medication reconciliation for care transitions, the measure defined within PCMH factor KM14 can be used as one care coordination measure:

Reviews and reconciles medications for more than 80 percent of patients received from care transitions.

This can be reported from the "Medication Reconciliation" measure within the "Modified Stage 2" Meaningful Use report in the EHR. You need to meet the 80% threshold to get credit for factor KM14, but for QI02 documentation you just need to show a numerator, denominator, and time period used for the measure. You don't need to meet the 80% threshold to get credit for QI02

  • Another care coordination measure that could be used for QI02 is based on the Portal message response time report in the EHR Report Library. This report will show the response time for portal messages being sent to you by patients. If you export that data to a spreadsheet and calculate average response time for portal messages over a reporting period, this would be a good example of a care coordination measure.

Other care coordination measures that can be used are related to referral tracking followup and ER followups.

  • NQF also has provided these examples of care coordination measures relevant to pediatrics:
    • Reconciled medication list received by discharged patients (inpatient discharge to home/self-care or any other site of care).
    • Transition record, with specified elements received by discharged patients (inpatient discharge to home/self-care or any other site of care).
    • Timely transmission of transition record (inpatient discharge to home/self-care or any other site of care).
    • Transition record, with specified elements received by discharged patients (emergency department discharges to ambulatory care [home/self-care]).

B. Measures affecting health care costs.

Description Example/Screenshot/Documentation Source Date Added
PCC eRx can report on utilization measure affecting health care costs such as:
  • Utilization of generic vs brand name prescriptions
  • Utilization of non-formulary medications

QI 03 (Core): Assesses performance on availability of major appointment types to meet patient needs and preferences for access.

QI 04 (Core): Monitors patient experience through:=

A. Quantitative data. Conducts a survey (using any instrument) to evaluate patient/family/caregiver experiences across at least three dimensions such as:

  • Access
  • Communication.
  • Coordination.
  • Whole-person care, self-management support and comprehensiveness.

B. Qualitative data. Obtains feedback from patients/families/caregivers through qualitative means.

QI 05 (1 Credit): Assesses health disparities using performance data stratified for vulnerable populations (must choose one from each section):

A. Clinical quality.

B. Patient experience