0 ICC Community CY 2013 Chart Audit September 9, 2014 Audit Timeframe: Jan 1, 2013 – Dec 31, 2013

1 Audit Participants CY 2013 Seton Community Health Centers CommUnityCare El Buen Samaritano Lone Star Circle of CarePeople’s Community Clinic Volunteer Healthcare Clinic Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.

2 Parameters CY 2013 Audit Timeframe: Jan 1, 2013 – Dec 31, 2013 ALL Denominators include the assumption that the patient is:  Active (defined as >/=1 visit at organization between Jan 1-Dec 31, 2013) AND adequately  Established (defined as first visit at organization prior to July 1, 2013) When an Age Range is included in the denominator, the patient must have been within that age range on Dec 31, 2013 When a Diagnosis is included in the denominator and/or numerator, audit participants should ensure that the diagnosis was Active (not Resolved) in a given patient during the audit timeframe When a Diagnosis is included in the denominator, numerator, or exclusion list, audit participants will determine the appropriate place(s) in their medical records/databases from which to pull the diagnosis (such as Assessments from encounters, Current/Chronic Problem List, etc). See the "Dx Code Sets" sheet for ICD-9 codes that correspond to the diagnoses being measured When a lab result is included in a numerator, audit participants will determine the appropriate place(s) in their medical records/databases from which to pull the results. Note that Orders are codified as CPTs and Results should be codified in LOINC, although many lab vendors return results with proprietary lab codes. A list of corresponding CPT and LOINC codes is included for the measures below. For audit participants with an EMR, the date to pull should be the Result Date (not Order Date or Recorded/Entered Date), if available When encounters are included in a numerator or denominator, it implies a face-to-face encounter with a provider. A lab-only visit, for example, would not be considered an encounter Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.

3 Electronic vs Manual Data Pull Poll CY 2013 Data collection 2012 vs 2013? Electronic, Manual or Combination (E/M/C) Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics. Note: Seton Community Health Centers: Data measures from April 1 – Dec 31, Only included in the denominator patients with current diagnosis of IVD because this was first year on EMR and didn’t have electronic data from prior year.

4 Tobacco Poll CY 2013 In your clinic, do you ask your patients about and document the status related to other tobacco use (non-cigarette)? Is there a timeline to make these changes? (no replies) Note: Technically can be asked separately within NexGen, but due to workflow issue this is not actually done Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.

5 Tobacco Use Screening CY ,890 6,191 36,071 36,722 5,536 5,563 5,729 5, ,055 51,261 Not Reported Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.

6 Tobacco Cessation Intervention CY ,640 5, ,434 9,566 Not Reported Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.

7 Blood Pressure Screening CY ,654 5,974 30,297 30,480 4,971 4,993 4,161 1,172 1,188 46,965 47,391 Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.

8 Follow-Up Blood Pressure Screening CY ,843 2, ,049 1,136 Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics. Not Reported DenominatorPatient age 18+ who have ever had a true diagnosis Hypertension and most recent reading is =>140/90 with one other reading, within 12 months of the most recent reading, being =>140/90. NumeratorLab or Treatment Or EKG within reporting year

9 Follow-Up Blood Pressure Screening CY ,384 3, ,711 2,027 Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics. Not Reported DenominatorPatient age 18+. With most recent reading is =>140/90 with one other reading, within 12 months of the most recent reading, being =>140/90. NumeratorLab or Treatment Or EKG within reporting year

10 Diabetes: No A1c Test Frequency CY , , ,606 Not Reported

11 Diabetes: A1c Test Frequency >=1 CY ,348 3, , , ,325 5,606 Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.

12 Diabetes: A1c Test Frequency >/=2 CY ,124 3, , ,718 5,606 Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.

13 Diabetes: A1c Ideal Control <7.0% CY ,495 3, ,062 2,021 5, Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.

14 Diabetes: A1c Control 7.0% through 7.99% CY , ,062 1,153 5, Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.

15 Diabetes: A1c Control <8.0% CY ,127 3, , ,174 5,606 Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.

16 Diabetes: A1c Control 8.0% through 9% CY , , ,606 Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.

17 Diabetes: A1c Poor Control >9.0% CY , , ,375 5,606 Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics. Note: No A1c included in >9 calculation

18 Diabetes: A1c CY 2013 Combined Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.

19 Diabetes: Lipid Panel Testing Frequency CY ,913 3, , ,867 5,606 Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.

20 Diabetes: LDL Control CY ,515 3, , ,861 5,606 Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.

21 Diabetes: No LDL CY , , ,606 Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.

22 Diabetes: Ideal Blood Pressure Control CY ,376 3, , ,336 5,606 Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.

23 Diabetes: Blood Pressure Control CY ,619 3, , ,973 5,606 Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.

24 Hypertension: Blood Pressure Control CY ,008 4,271 7, ,474 1, ,740 8,192 Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.

25 Hyper-Cholesterolemia LDL Control CY , ,888 Not Reported Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.

26 Hyper-Cholesterolemia No LDL , ,888 Not Reported Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.

27 Hyper-Cholesterolemia Combined CY 2013 Combined Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics. Not Reported

28 IVD: Aspirin Use CY Not Reported Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.

29 IVD: Lipid Panel Testing Frequency CY Not Reported Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.

30 IVD: LDL Control CY Not Reported Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics.

31 IVD: No LDL CY Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics. Not Reported

32 IVD: LDL CY 2013 Combined Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics. Not Reported

33 IVD: Blood Pressure Control CY Not Reported Note: Data in this report has been provided by the individual reporting clinics, and therefore the ICC cannot directly verify the accuracy of the data. Since ICC cannot know for certain if there were any variations in data collection methodology and other variables, the reader should exercise caution in attempting to draw comparisons between clinics. 0000