The practice uses patient information, clinical data and evidence-based guidelines to generate lists of patients and to proactively remind patients/families and clinicians of services needed for:
PCMH 2.D.1 At least three different preventive care services
|Examples of using the recaller and Dashboard for generating lists and reminding patients of preventive care services||Preventive care reporting examples||PCC||07/07/14|
|For patients overdue for well visits, choose an age group to focus on depending on where there is opportunity for improvement. For example, many practices see a decline in well visit rates for kids between the ages of 7 and 11. Your PCC Dashboard is the easiest place to find this data - look under "Clinical Conditions -> % of Patients Up-to-Date on Well Visits".
You can also use the PCC Recaller to further restrict or identify those who need well visits. The recaller can also restrict by primary care provider to report these measures for individual provider which something that needs to be done for PCMH element 6E.
|PCC Dashboard and/or Patient Recaller||03/22/13|
|Asthma patients overdue for a seasonal flu shot.The Dashboard is the best place to get this information since the % is calculated and tracked monthly for you and you can get a listing of overdue patients. This is a seasonal measure and shows asthma patients overdue for a flu shot this season.||Dashboard||03/22/13|
|Patients overdue for developmental screening.These calculations and patient lists can be generated from the Partner recaller report by looking for the presence of the 96110 CPT code billed within a specific time period. This code should be used for any type of standardized developmental screening. If you want to track different types of standardized screenings (Vanderbilt, MCHAT, etc), create a unique procedure table entry for each type of test and remember to select the appropriate procedure table entry when charting or billing.The practice implements evidence-based guidelines through point of care reminders for patients with: The first important condition The second important condition||recaller||03/22/13|
|Patients overdue for immunizations.You may want to pick a particular immunization and age range to focus on. The Partner 'epidemic' program can be used to generate a list of patients overdue, although it does not report a % overdue and PCC support would need to configure the "rule set" depending on which immunization(s) and ages you wanted to focus on. There is a "Childhood Immunization" CQM report in PCC EHR that can show % of patients up- to-date on individual vaccines recommended to be given by age 2. However, this report does not show a list of overdue patients.||epidemic or PCC EHR CQM report|
|Patients overdue for a newborn hearing screening.You can use the recaller report to identify patients who may be in need of a newborn hearing screening. You would look for the the presence of a hearing screening CPT code given during the specific date range.||recaller|
|Patients overdue for pre-school vision screening. The recaller could be used to generate a count and list of patients in the 4-5 year old range who have not had a CPT code billed that would indicate visual acuity testing or photoscreening.||recaller|
|Risky Behavior Assessment or Counseling by Age 13 Years.. This is an NQF- endorsed measure showing the percentage of children with documentation of a risk assessment or counseling for risky behaviors by the age of 13 Years. Four rates or overdue lists can be reported:
You may want to focus on measuring assessment or counseling for tobacco or alcohol/substance use since there are specific CPT codes (99406-99409) that can be used for these. Using these CPT codes will allow recaller to capture a count and list of patients who may be overdue for this particular assessment. Note that there is also a "Tobacco Counseling" CQM report in the EHR which will provide a %, but that report does not provide a *listing* of patients who did not get the counseling.
2.D.2 At least three different chronic or acute care services
Here are some examples of chronic care services that you may want to choose from depending on what's most important to your practice.
|Examples of using the recaller and Dashboard for generating lists and reminding patients of chronic care services||Chronic care reporting examples||PCC||07/07/14|
|ADD/ADHD patients overdue for checkup. A % of patients overdue and a listing of overdue patients is available in the Dashboard. Patients diagnosed with ADD (314.00) or ADHD (314.01) in the past three years are included. They are considered overdue if they have not been seen (for any visit type) in the past six months. You can also get this information from recaller where you can also restrict by primary care provider to report these measures for individual provider which something that needs to be done for PCMH element 6E.||Dashboard and/or recaller||03/22/13|
|Asthma patients overdue for checkup.You can get this information from recaller where you can also restrict by primary care provider to report these measures for individual provider which something that needs to be done for PCMH element 6E.||recaller||03/22/13|
|Obesity patients overdue for checkup.You can get this information from recaller where you can also restrict by primary care provider to report these measures for individual provider which something that needs to be done for PCMH element 6E. The EHR Patient lists report can also be used to show patients who have been diagnosed in a particular percentile for BMI.||recaller or PCC EHR Patient Lists||03/22/13|
|Patients with depression overdue for medication checkup.You could use the EHR “Patient Listing” feature to generate a list of patients:
||EHR Patient Lists||03/22/13|
|Patients with allergic rhinitis overdue for followup.You can get this information from recaller where you can also restrict by primary care provider to report these measures for individual provider which something that needs to be done for PCMH element 6E.||recaller||03/22/13|
2.D.3 Patients not recently seen by the practice
To identify patients who may have been overlooked and are in need of services, you would use the Partner recaller report to generate a list of patients who you haven't seen in a while. Use restriction of "Patient Last Visit Date"
|Examples of using the recaller to identify patients not recently seen by the practice||How to identify patients not recently seen||PCC||07/07/14|
2.D.4 Specific medications
You could use the "Patient Lists" functionality in PCC EHR to generate a list of patients given certain medications. This could be used to:
- Manage patients who were prescribed medications with potentially harmful side effects
- Identify patients who would have been prescribed a certain brand name drug versus a generic
- Notify patients about a medication recall
|Example of generating lists of patients given certain medications||How to identify patients given certain medications||PCC||07/07/14|