2014 - PCMH6B

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At least annually, the practice measures or receives quantitative data on:

6.B.1 At least two measures related to care coordination.

• As it is related to medication reconciliation for care transitions, the measure defined within PCMH factor 4C.1 can be used as one care coordination measure:

Reviews and reconciles medications for more than 50 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 50% threshold to get credit for factor 4C.1, but for 6B.1 documentation you just need to show a numerator, denominator, and time period used for the measure. You don't need to meet the 50% threshold to get credit for 6B.1

• Another care coordination measure that could be used for 6B.1 is defined within PCMH factor 5B.7:

"Has the capacity for electronic exchange of key clinical information+ and provides an electronic summary of care record to another provider for more than 50 percent of referrals."

This is reported as the "Summary of Care (Transmitted Only)" measure on the modified stage 2 MU report. Again, to use this and get credit for 6B.1 you only need to define a numerator, denominator, and time period used for the measure.

• For multi-location practices, you do need to report these measures individually by location. Each of your providers should be attributed to a single "home location" and you can then run the MU reports mentioned above filtering by individual providers attributed to each location.

• Another care coordination measure that could be used for 6B.1 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, I think 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. For example, you may set an internal goal for your practice to do an initial follow up on referral orders within 7 days. There isn't an EHR report to identify how long it took for each referral order to be completed. You'd need to review recent referral orders and identify the time between the original order and the initial followup task being completed.

• NCQA says that measuring adherence to agreements PCMH 5, Element B may be used to meet the factor.

• 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]).

6.B.2 At least two utilization 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	Using PCC eRx to report on two utilization measures affecting health care costs	PCC	07/07/14
Various Reports and Samples. These reports are generated from Partner, the PCC Dashboard, or the PCC EHR	Examples	TPC	03/25/13