PCMH2D
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 developmental screening.
- 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). |   |
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 | 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
- Asthma patients overdue for checkup
- Obesity patients overdue for checkup
- Patients with depression overdue for checkup
- Patients with allergic rhinitis overdue for followup
| Description | Example/Screenshot/Documentation | Source | Date Added |
|---|---|---|---|
| ADHD patients overdue for checkup | Details on various measures reportable from Partner/PCC EHR | PCC | 03/21/13 |
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