PCMH2D

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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:

At least three different preventive care services

Here are some examples of preventive care services that you may want to choose from depending on what's most important to your practice. For more details on preventive and chronic care services and how you could use Partner and/or PCC EHR tools to generate these lists of patients, please refer to this document

• Patients overdue for Newborn hearing screening.
• Pre-School Vision Screening in the Medical Home.
• Risky Behavior Assessment or Counseling by Age 13 Years.
• Sudden Infant Death Syndrome Counseling.

Description	Example/Screenshot/Documentation	Source	Date Added
Patients overdue for well visits, picking a certain age group to focus on depending on where there is opportunity for improvement. For example, children 3-6 years old who are overdue for a well visit. 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. You can also get this information from recaller (with the exception of the under 15 mos measure since this counts # well visits performed before age 15mos which recaller can't do). 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	Well visit rates from the Dashboard Example restriction criteria from recaller	Dashboard and/or 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 report of Asthma patients overdue for a flu shot	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.	Patients turning 2 in past year who haven't had a developmental screening	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	03/22/13

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. For more details on preventive and chronic care services and how you could use Partner and/or PCC EHR tools to generate these lists of patients, please refer to this document

Description	Example/Screenshot/Documentation	Source	Date Added
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 report of ADD/ADHD patients overdue for a followup visit recaller criteria to get total active ADD/ADHD patient count recaller criteria to get total active overdue ADD/ADHD patient count	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.		recaller	03/22/13
Patients with depression overdue for medication checkup.You could use the EHR “Patient Listing” feature to generate a list of patients: Diagnosed with depression in a time frame Who are also on depression meds (selecting appropriate meds) Not seen for a visit during a certain time period. (Have not had a certain Dx code to indicate they were seen for a visit)	Example criteria to use in EHR Patient Lists	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

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"

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