1. NCQA Standards Workshop Physician Practice Connections - Patient-Centered Medical Home (PPC ® -PCMH™) 2009

2. 2 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Agenda Patient-Centered Medical Home Overview Content of PPC-PCMH – Standards – Documentation examples* Recognition Process * Examples in the presentation only illustrate the element intent. They are NOT definitive nor the only methods of documenting how the elements may be met

3. 3 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 The Patient-Centered Medical Home Defined ACP, AAFP, AAP, AOA Joint Principles – April 2007 Personal physician – each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care. Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients. Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care. Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

4. 4 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC-PCMH Content and Scoring Standard 1: Access and Communication A.Access and communication processes** B.Access and communication results** Pts 4 5 9 Standard 2: Patient Tracking and Registry Functions A.Basic system for managing patient data B.Electronic system for clinical data C.Use of electronic clinical data D.Organizing clinical data** E.Identifying important conditions ** F.Use of system for population management Pts 2 3 6 4 3 21 Standard 3: Care Management A.Guidelines for important conditions ** B.Preventive service clinician reminders C.Practice organization D.Care management for important conditions E.Continuity of care Pts 3 4 3 5 20 Standard 4: Patient Self-Management Support A.Documenting communication needs B.Self-management support** Pts 2 4 6 Standard 5: Electronic Prescribing A.Electronic prescription writing B.Prescribing decision support - safety C.Prescribing decision support - efficiency Pts 3 2 8 Standard 6: Test Tracking A.Test tracking and follow up** B.Electronic system for managing tests Pts 7 6 13 Standard 7: Referral Tracking A.Referral tracking** Pts 4 4 Standard 8: Performance Reporting and Improvement A.Measures of performance ** B.Patient experience data C.Reporting to physicians ** D.Setting goals and taking action E.Reporting standardized measures F.Electronic reporting to external entities Pts 3 2 1 15 Standard 9: Advanced Electronic Communications A.Availability of interactive website B.Electronic patient identification C.Electronic care management support Pts 1 2 1 4 ** Must Pass Elements

5. 5 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC-PCMH Scoring Level of Qualifying Points Must Pass Elements at 50% Performance Level Level 375 - 10010 of 10 Level 250 – 7410 of 10 Level 125 – 495 of 10 Not Recognized0 – 24< 5 Levels: If there is a difference in Level achieved between the number of points and “Must Pass”, the practice will be awarded the lesser level; for example, if a practice has 65 points but passes only 7 “Must Pass” Elements, the practice will achieve at Level 1. Practices with a numeric score of 0 to 24 points or less than 5 Must Pass Elements are not Recognized.

6. 6 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PCMH Must Pass Elements 1.PPC1A: Written standards for patient access and patient communication 2.PPC1B: Use of data to show meeting this standard 3.PPC2D: Use of paper or electronic-based charting tools to organize clinical information 4.PPC2E: Use of data to identify important diagnoses and conditions in practice 5.PPC3A: Adoption and implementation of evidence-based guidelines for three conditions 6.PPC4B: Active support of patient self-management 7.PPC6A: Tracking system for tests and to identify abnormal results 8.PPC7A: Tracking referrals with paper-based or electronic system 9.PPC8A: Measurement of clinical and/or service performance 10.PPC8C: Performance reporting by physician or across the practice

7. 7 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Data Sources & Health Information Technology (HIT) Guidance Elements may have multiple suggestions for data sources and documentation– select what your practice would use to demonstrate that function and describe how it is used Each element indicates the type of health information technology needed to perform the functions – Basic – (HIT) Basic Paper-based or basic (mostly administrative) electronic system – Intermediate – (HIT) Intermediate Electronic system for clinical functions – Advanced – (HIT) Advanced Electronic system with connectivity or interoperability with other systems

8. 8 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PCMH Elements by Type of Information Technology (IT) BasicIntermediateAdvanced PPC 1 A - BPPC 2 B, C, FPPC 6 B PPC 2 A, D, EPPC 5 A - CPPC 8 F PPC 3 A - EPPC 8 E PPC 4 A - BPPC 9 A - C PPC 6 A PPC 7 A PPC 8 A - D TOTAL = 18TOTAL = 10TOTAL = 2 Practice can achieve a passing score on Must Pass Elements with Basic Information Technology

9. 9 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC1 - Access and Communication Patient access to care and communication PPC1A: Access and communication processes PPC1B: Access and communication results

10. 10 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC 1 Element A: Access and communication processes Practice has written process for*: – Scheduling patients with same clinician – Coordinating visits with multiple clinicians during one trip – Determining how soon a patient needs to be seen – Responding to urgent calls within specified time – Providing telephone advice – Providing language services *Shows 6 of 12 items in Element A Must Pass - 4 points Scoring: based on 12 items – 9-12 items = 100% – 7-8 items = 75% – 4-6 items = 50% – 2-3 items = 25% – 0-1 item = 0% Documentation: – Written process – Policies and procedures – Instructions – Appointment system

11. 11 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC1A: Scheduling Policy

12. 12 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC 1 Element B: Access and communication results Practice shows how it meets patient access and communication standards – Visits with assigned physician – Appointments scheduled to accommodate patient condition and need – Timely response to phone, e-mail and Internet requests – Language services if the practice’s population requires it Must Pass - 5 points Scoring: Based on number of items met of 5 – 5 items = 100% – 4 items = 75% – 3 items = 50% – 2 items = 25% – 0-1 item = 0% Data source: – Reports – Logs or screen shots showing records of appts. scheduled and time for returning calls

13. 13 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Access Standards with Specific Targets and Result Measurements Standards Results Measurements

14. 14 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC2 - Patient Tracking and Registry Functions Systematic use of patient information for population management to support patient care PPC2A: Basic System for Managing Patient Care PPC2B: Electronic System for Clinical Data PPC2C: Use of Electronic Clinical Data PPC2D: Organizing Clinical Data PPC2E: Identifying Important Conditions PPC2F: Use of System for Population Management

15. 15 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC2A: Basic System for Managing Patient Data Practice uses electronic data system for searchable patient information 1-9. Name, DOB, gender, marital status, language preference, race/ethnicity, address, phone, email 10-11. Internal and external IDs 12. Emergency contact info. 13. Current and past diagnoses 14. Dates of prior visits 15. Billing code 16. Legal guardian 17. Health insurance coverage 18. Preferred method of communication 2 points Scoring: Number of items met of 18 – 12-18 items = 100% – 8-11 items = 75% – 6-7 items = 50% – 4-5 items = 25% – 0-3 items = 0% Data source: – Reports from electronic system showing data items entered for 75- 100% of patients

16. 16 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Element A- Report Showing Basic Patient Information Field Use

17. 17 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC2B: Electronic System for Clinical Data Practice uses clinical data systems to manage care of patients has searchable data fields for clinical patient information: 1.Preventive services 2.Allergies/adverse reactions 3.Blood pressure 4-5. Height and Weight 6. BMI 7-9. Lab test, imaging and pathology results 10.Advance directives 11.Head circumference (for patients ≤ 2 years 3 points Scoring: Number of items met of 10 – 9-10 items = 100% – 7-8 items = 75% – 5-6 items = 50% – 3-4 items = 25% – 0-2 items = 0% Data source: – Reports or screen shots showing data fields in patient records

18. 18 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Example PPC2B: Screen Shot of Data Fields for Clinical Data

19. 19 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC2C: Use of Electronic Clinical Data Practice uses the fields listed in 2B consistently in patient records 1.Preventive services 2.Allergies 3.Blood pressure 4-5. Height and Weight 6. BMI 7-9. Lab test, imaging and pathology results 10. Advance directives 3 points Scoring: Practice enters a percentage of patients seen in past 3 months with 7 fields completed: – 75-100% of patients = 100% – 50-74% of patients = 75% – 25 -49% of patients = 50% – 10-24% of patients = 25% – <10% of patients = 0% Data source: – Reports from electronic system OR – Record Review Workbook

20. 20 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Element C: Report of percent of patients with clinical data items entered in system

21. 21 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 What is the Record Review Workbook? Elements PPC 2C, 2D, 3D, 4B Require medical record abstraction of data Need % of patients based on numerator and denominator Two methods to collect and submit patient data – Method #1 - report from the electronic system – Method #2 – Record Review Workbook Excel workbook in the Survey Tool Tool to identify sample of patients and abstract data needed for Elements 2C, 2D, 3D, 4B

22. 22 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Example PPC 2C, 2D, 3D, 4B Option NCQA Medical Record Review Worksheet

23. 23 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Selecting Patients for Record Review Workbook ~Use same 36 patients for EACH Workbook Element~ STEP #1. START DATE = Today’s date June 1 STEP #2. Go back 30 days = May 1 STEP #3. Use appointment or billing system to identify patients with visit on April 30 Choose patients with any of three clinically important conditions who had a visit on this date related to the conditions STEP #4. Continue choosing patients going back on consecutive dates until all 36 patients are selected

24. 24 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC2D: Organizing Clinical Data Practice uses paper or electronic charting tools used to organize and document clinical information 1.Problem lists 2.Medication lists (OTC) 3.Medication lists (RX) 4.Template for risk factors 5.Templates for progress notes 6.Screening for developmental testing 7.Growth charts & BMI Based on number of items documented in records of patients seen in last 3 months Must Pass – 6 points Scoring - % of patients with 3 tools documented: – 75-100% = 100% – 50-74% = 75% – 25-49% = 50% – 10-24% = 25% – <10% = 0% Data source – Record Review Workbook or – Electronic system report with percent of patients seen in past 3 months

25. 25 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC 2D - what to look for in the medical record: Documented Risk Factors And Medication Lists In Paper Flow Sheet

26. 26 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC2D: Pediatric Weight Chart

27. 27 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC2E: Identifying Important Conditions Practice identifies 1.Most frequently seen diagnoses = most often seen, single episode or chronic; identify by number of patients, visits, total fees billed 2.Most important risk factors = for the demographic population 3.Three clinically important conditions (chronic or recurring) = practice identifies Must Pass – 4 points Scoring – 3 items = 100% – 2 items = 75% – 1 item = 50% – 0 items = 0% Data source – Reports from EHR, practice management system, billing or scheduling system for frequent Dx – Identify risk factors in reports – Identify conditions and why selected in the Support Text/Notes section

28. 28 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC2E: Example Text Notes in Survey Tool “Attached are 3 reports: 1.Frequent diagnoses: Dates of service and the diagnosis codes, sorted by codes for frequency. 2.Risk factors: Source of Community Statistics for Risk Factors - www.CDC.gov and http://apps.nccd.cdc.gov/brfss/display_PF.aspwww.CDC.gov http://apps.nccd.cdc.gov/brfss/display_PF.asp 3.Clinically important conditions: As part of a National PCMH Demonstration Project, the Demonstration Project Stakeholders have chosen Diabetes, Hypertension and Hyperlipidemia which represent the best likelihood of being amenable to care management and providing value on costs to the health care system based on regional experience.”

29. 29 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC2F: Use of System for Population Management Practice uses electronic information to generate lists of patients and remind patients and clinicians proactively of services needed: 1.Pre-visit planning 2.Clinician action 3.Specific medications 4.Preventive care 5.Specific tests 6.Follow-up visits 7.Care management services 3 points Scoring: Practice takes action on – 5-7 items = 100% – 3-4 items = 75% – 1-2 items = 50% – 0 items = 0% – Practice gets partial credit If system can generate lists but practice does not use it Two Data sources: 1.Lists generated -- reports from EHR, registry and 2.Example of use of the lists -- screen shots, written description of process

30. 30 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Population Management Examples EHR Query-Patients Needing Pneunomax vaccine Report – Patients on a Specific Medication

31. 31 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC3: Care Management Practice maintains continuous relationship with patients by using evidence-based guidelines and applying them to needs of individual patients over time. PPC3A: Guidelines for Important Conditions PPC3B: Preventive Service Clinician Reminders PPC3C: Practice Organization PPC3D: Care Management for Important Conditions PPC3E: Continuity of Care

32. 32 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC3A: Guidelines for Important Conditions Practice adopts and implements evidence-based diagnosis and treatment guidelines for three clinically important conditions Use same conditions in PPC2D, 2E, 3A, 3D, 4B, 9C Must Pass – 3 points Scoring – 3 conditions = 100% – 2 conditions = 50% – 1 condition = 25% – 0 conditions = 0% Data source: workflow organizers that show guidelines adopted and implemented – Provide source of guidelines – Paper flow sheets, templates for documenting progress – Screen shots showing templates for treatment plans and documenting progress

33. 33 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Example PPC3A – Adoption of Evidence –Based Diagnosis and Treatment Guidelines

34. 34 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Example – Evidence-Based Diabetic Workflow Organizer (shows what to document at each visit)

35. 35 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Example PPC3A - EHR Prompting Lipid Management Evidence-Based Guidelines

36. 36 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC3B: Preventive Service Clinician Reminders Practice generates reminders about preventive services for clinicians Practice uses paper or electronic guideline-based alerts and reminders to write orders and conduct assessments 1.Screening tests 2.Immunizations 3.Risk assessments 4.Counseling 4 points Scoring – Reminders for 4 items = 100% – Reminders for 3 items = 75% – Reminders for 2 items = 50% – Reminders for 1item = 25% – Reminders for no items = 0% Data source: reports, screen shots, templates or paper flow sheets showing decision- support for clinicians during visits, calls and email.

37. 37 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Example PPC3B - Preventive Service Reminders for Clinicians Paper Reminder for Risk Assessments, Immunizations, Screening Tests EHR with Risk Assessment Reminders

38. 38 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC3C: Practice Organization Care team manages patient care: 1.Non-physician staff remind patients of appointments and collect information before appointments 2.Non-physician staff execute standing orders (e.g. med. refills, order tests) 3.Non-physician staff educate patients to manage conditions 4.Non-physician staff coordinate care with external disease management or case management organizations 3 points Scoring – 4 items = 100% – 3 items = 75% – 2 items = 50% – 0-1 item = 0% Data source – Job descriptions – Protocols – Written standing orders

39. 39 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Example PPC3C: Practice Organization Standing Orders Note: If patient needs OV or labs, refill up to one month (one time only). If more requested, check with physician

40. 40 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC3D: Care Management for Important Conditions To manage care of patients with three clinically important conditions, practice uses: 1.Pre-visit planning 2.Individualized written care plans 3.Individualized treatment goals 4.Assess progress toward goal 5.Review of medications with patients 6.Review self-monitoring results and include in medical record 7.Assess barriers when patient not met treatment goals 8.Assess barriers when patient not filled prescriptions or took meds. 9.Follow-up when patient not kept important appointments 10.Review patient clinical data over time 11.After-visit follow-up 5 points Scoring – patients seen in past 3 months have 4 items documented: – ≥75% of patients = 100% – 50-74% of patients = 75% – 25-49% of patients = 50% – 11-24% of patients = 25% – ≤10% of patients = 0% Data source – Report from electronic system showing percent of patients seen with documentation of items OR – Record Review Workbook

41. 41 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC3D: Written Care Plan in Medical Record

42. 42 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Patient Progress, Treatment Goals and Medication Review Patient Progress and Treatment Goals Treatment plan and goals Patient progress PPC 3D - what to look for in the medical record: Documented Patient Progress and Treatment Goals Medication Review Assessment & Plan

43. 43 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC3E: Continuity of Care Practice provides continuity of care for patients who receive care in inpatient or outpatient facilities 1.Identifies patients 2.Sends information to facilities and patients 3.Reviews information from facilities to identify patients needing proactive contact or are at risk for adverse outcomes 4.Contacts patients post-discharge 5.Provides or coordinates follow-up care to discharged patients 6.Coordinates care with external disease or care management organizations 7.Communicates with patients getting disease or high risk case management 8.Communicates with case managers for patients getting disease or high risk case management 9. Develops written transition plan with patient for transition to other care 10.Coordinates with new physicians 5 points Scoring – 5-10 items = 100% – 3-4 items = 75% – 2 items = 50% – 0-1 item = 0% Data source: from practice or external organization – Protocols re: timeline for patient follow-up – Protocols for care plans – Log of patients receiving care from other facilities – Registry, EHR, hospital or ER reports – Health needs assessments – Blinded case management or medical record notes

44. 44 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Example – ER Visit Follow-Up Log

45. 45 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Example – Follow-Up Care after Hospital Admission

46. 46 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC4 - Patient Self-Management Support Improve patient ability for self-management by: PPC 4A - Documenting communication needs PPC 4B - Providing self-management support

47. 47 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC4A: Documenting Communication Needs Practice assesses patient-specific barriers to communication using systematic process to: 1.Identify and display in record patient language preference 2.Assess both hearing and vision barriers 2 Points Scoring: – 2 items = 100% – 1 item = 50% – 0 items = 0% Data source - How practice – Records language preference: screen shots, patient assessment forms – Determines % of patients preferring another language: reports from EHR, patient record review

48. 48 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC4A: Example Documenting Communication Needs

49. 49 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC4B: Self-Management Support Practice documents patient self-management support for 3 clinically important conditions 1.Assess patient preferences, readiness and ability for self- management 2.Provides educational resources in patient language 3. Provides self-monitoring tools for patients 4-6. Provides or connects patient with support programs, classes, resources 7. Provides patient with written care plan Must Pass – 4 points Scoring – % of patients seen in past 3 months have 3 items documented: – 75-100% patients = 100% – 50-74% = 75% – 25-49% = 50% – 11-24% = 25% – ≤10% = 0% Data source – Record Review Workbook or – Report from electronic system

50. 50 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC 4B - what to look for in the medical record: Documented Use of Self-Monitoring Tools & Program Referrals

51. 51 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC5: Electronic Prescribing Practices uses electronic systems to order prescriptions, to check for safety and to promote efficiency when prescribing. PPC5A: Electronic Prescription Writing PPC5B: Prescribing Decision Support – Safety PPC5C: Prescribing Decision Support – Efficiency

52. 52 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC5A: Electronic Prescription Writing Practice uses an electronic system to write prescriptions 1.Stand-alone system (i.e., hand-held e-prescribing device, PDA) 2.System that links data to specific patients (i.e., EHR) 3 points Scoring – 75-100% of prescriptions for patients seen in past 3 months written with item 2 = 100% – 75-100% of prescriptions for patients seen in past 3 months written with item 1 = 75% – System capable of either item 1 or 2 but practice does not use or cannot report %= 25% – No system capability or <75% of item 1 or 2 = 0% Data source : – Reports showing practice used system for writing prescriptions for 75-100% of patients within past 3 months

53. 53 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC5A: Example Prescribing Method EXPLANATION January to March 2009 prescribing method is documented in the table. Certain prescriptions (Schedule II) must be printed on special paper prescription pads in our state. 96% of prescriptions were generated from our electronic medical record. January to March 2009 prescribing method is documented in the attached spreadsheet. Certain prescriptions (Schedule II) must be printed on special paper prescription pads in our state. Overall, 96% of prescriptions were generated from our electronic medical record.

54. 54 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Example PPC 5A - % of Use for Electronic Prescriptions Evaluation: Our Physicians and nurses put all prescriptions in our EMR which is linked to patient -specific demographic and clinical data. Note the screen shot that denotes the number of scripts for our physicians in the last three months, 2046 and the report which notes the number of patients seen during that same time period, 2482. We propose that this represents a percentage between 75% and 100%, understanding that one prescription does not mean one patient. 2046 prescriptions provides the numerator to determine the percentage. The practice provided another report showing the summary of the 2482 patients seen during the same period to provide the denominator

55. 55 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC5B: Prescribing Decision Support – Safety Electronic prescription reference information at the point of care including alerts and information: 1-2. drug-drug interactions - general and patient-specific 3-4. drug-disease interactions – general and patient-specific 5-6. Drug-allergy alerts - general and patient-specific 7. Drug-patient history alerts 8-9. Appropriate dosing – general and patient specific 10.Drug-lab alerts – general 11-12. Duplication of drugs – general and patient-specific 13-14. Drugs to be avoided in elderly 15. Patient-appropriate medication information 3 points Scoring – Practice uses ≥8 alerts and information = 100% – Practice uses 4-7 alerts and information = 75% – Practice uses 2-3 alerts = 50% – System has >6 alerts but not used = 25% – No system capability or <6 alerts or practice uses <2 alerts Data source: – Reports from system, showing example of each item

56. 56 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Example PPC5B - EHR Prescription Allergy Pop Up Box (safety check)

57. 57 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC5C: Prescribing Decision Support – Efficiency Cost-efficient electronic prescription writer with: 1.Automatic alerts for drug choices, including generics 2.Payer-specific formulary that alerts clinician to alternative drugs, including generics 2 points Scoring – Practice uses 2 tools = 100% – Practice uses 1 tool = 75% – System has both tools but practice doesn’t use it = 25% – System lacks capability or practice does not use either tool = 0% Data source – Reports – Screen shots – Practice protocols

58. 58 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC5C: Prescribing Decision Support – Efficiency

59. 59 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC6 - Test Tracking Practice systematically tracks tests ordered and test results, and systematically follows up with patients. PPC 6A - Test tracking and follow-up Basic – if paper system Intermediate – if electronic communication within the practice office Advanced – if electronic communication between practice and lab and imaging facilities PPC 6B - Electronic system for managing tests

60. 60 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC6A: Test Tracking and Follow-up Practice uses paper or electronic system to track tests and follow up 1.Tracks lab tests until results return to practice and flag overdue results 2.Tracks imaging tests until results return to practice and flag overdue results 3.Flag abnormal test results 4.Notify patients of abnormal results 5.Follows up with inpatient facility on hearing and metabolic screening 6.Notifies patients of normal results Must Pass – 7 points Scoring – 4-6 items = 100% – 3 items = 50% – System can do 4 types of tracking but isn’t in use = 25% – System can’t track or practice uses <3 types of tracking and follow-up = 0% Data source: – Evidence that practice reviews and uses tracking log before or at beginning of patient visits – Reports or tracking logs or e- mail inbox flagging results Filing results in the medical record until patient comes in does not meet tracking and follow-up standard

61. 61 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Example PPC6A - Lab Tracking Manual LogSpreadsheet

62. 62 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC6A: Example Notifies Patient of Abnormal Results

63. 63 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC6B: Electronic System for Managing Tests Electronic system to 1-2. Order lab and imaging tests 3.Retrieve results from source 4-5.Retrieve imaging text and images from source 6.Route and manage current and historical test results to appropriate personnel for review 7.Flag duplicate tests 8.Generate alerts for appropriateness Assumes electronic communication between practice and lab and imaging facilities 6 points Scoring – 5-8 functions = 100% – 3-4 functions = 75% – 1- 2 functions = 50% – Doesn’t use system = 0% Data source – Reports or screen shots showing examples of required functions – Filing results in the medical record until patient comes in does not suffice for tracking and follow-up

64. 64 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Example PPC6B - EHR Order Screens Laboratory Test Order ScreenRadiology Test Order Screen

65. 65 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC7 - Referral Tracking PPC 7A - Document and track referrals and referral results

66. 66 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Example PPC7A - Manual Consultant Tracking Logs

67. 67 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC7A: Example Referral Results REFERRAL RESULTS Caregiver Patient Dates Status (Reviewed) Type (Referrals) Patient/Procedure Date Ordered

68. 68 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC8: Performance Reporting and Improvement Practice regularly measures its performance and takes actions to continuously improve PPC8A: Measures of Performance PPC8B: Patient Experience Data PPC8C: Reporting to Physicians PPC8D: Setting Goals and Taking Action PPC8E: Reporting Standardized Measures PPC8F: Electronic Reporting ─ E xternal Entities

69. 69 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC8A: Measures of Performance Practice measures or receives clinical and/or service performance data 1.Clinical process 2.Clinical outcomes 3.Service data 4.Patient safety issues Reports may be generated by the practice, an affiliated medical group or health plan Credit given for NCQA Recognition for items 1 and 2 Must Pass – 3 points Scoring – performance measurement: – 2 types = 100% – 1 type = 50% – No measures = 0% Data source - Reports from – Manual review of sample of patient records – Patient surveys – Practice management system – Registry – Data from health plan or larger medical group – Electronic database

70. 70 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 NCQA Clinical Program Recognition Where Can it Be Used to Meet Element? NCQA Clinical Recognition Programs – Diabetes Recognition Program (DRP) – Heart/Stroke Recognition Program (HSRP) – Back Pain Recognition Program (BPRP) Credit for Clinical Program Recognition may be used for meeting requirements in 7 elements if majority of physicians are Recognized: – PPC 3A, 3D (for selected conditions used for survey) – PPC 8A, 8C, 8D, 8E, 8F

71. 71 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Example PPC8A – Plan and Network Level Reports CAHP’s Patient Satisfaction Report Clinical Performance Report

72. 72 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC8B: Patient Experience Data Practice collects data on patient experience with are: 1.Patient access to care 2.Quality of physician communication 3.Patient confidence in self- care 4.Patient satisfaction with care 3 points Scoring – practice collects data on – 3-4 areas = 100% – 1-2 areas = 50% – 0 areas = 0% Data source: – Reports of paper, telephone, or electronic survey – Practice must provide summarized data, not a blank survey

73. 73 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC8B: Patient Experience Data

74. 74 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC8C: Reporting to Physicians Practice reports performance on measures in PPC8A 1.Across the practice 2.By individual physician Must Pass – 3 points Scoring - practice reports: – Across practice and by physician = 100% – Either across practice or by physician = 50% – No reporting = 0% Data source: – Blinded reports with performance data – Blinded letters to physicians with performance data

75. 75 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Example of B – Reporting Across the Practice and Across Multiple Practice Sites

76. 76 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC8D: Setting Goals and Taking Action Practice uses performance data to 1.Set goals based on performance data in PPC8A and 8B 2.Takes action to improve performance of individual physicians or practice 3 points Scoring – 2 items = 100% – 1 items = 50% – 0 items = 0% Data source: – Practice-specific reports or – Completion of NCQA’s Quality Improvement Workbook

77. 77 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Example PPC8D – NCQA’s QI Worksheet Documenting Setting Goals And Taking Action

78. 78 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC8E: Reporting Standardized Measures Practice produces reports on performance using nationally approved clinical performance measures – National Quality Forum endorsed physician level measures 2 points Scoring based on number of measures the practice reports – ≥10 items = 100% – 5-9 items = 75% – 3-4 items = 50% – 0-2 items = 0% Data source: – Reports showing performance measures calculated by practice

79. 79 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Example PPC8E - National Quality Forum Endorsed Physician Level Measures

80. 80 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PP8F: Electronic Reporting  External Entities Practice electronically reports results on nationally approved measures to external entities Practice gets partial credit if its system has the capability to report data but does not use it 1 point Scoring based on number of measures practice reports – ≥10 measure = 100% – 5-9 measures = 75% – 3-4 measures = 50% – 1-2 measures = 25% – 0 measures = 0% Data source: – Report to public sector, health plans or others

81. 81 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PP8F: Example Electronic Reporting  External Entities

82. 82 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC9: Advanced Electronic Communication Practice uses electronic communication to improve timeliness, effectiveness, efficiency and coordination of care. PPC9A: Availability of Interactive Web Site PPC9B: Electronic Patient Identification PPC9C: Electronic Care Management Support

83. 83 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC9A: Availability of Interactive Web Site Patient has access to Interactive Web site to: 1.Request appointments 2.Request referrals 3.Request test results 4.Prescription refills 5.See medical record 6.Import medical data to personal records 1 point Scoring – practice provides – 5-6 items = 100% – 3-4 items = 75% – 1-2 items = 50% – 0 items = 0% Data Source: screen shots showing Web functionality

84. 84 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC9A: Example Interactive Website Factor 2, Requesting Appointment

85. 85 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC9B: Electronic Patient Identification Electronic information and clinical decision- support to contact patients by email needing: 1.Clinical review or action 2.On a particular medication 3.Preventive care 4.Special tests 5.Follow-up visits 6.Disease/case management support 2 points Scoring – 5-6 items = 100% – 3-4 items = 75% – 1-2 items = 50% – 0-1 items = 0% Data source – Screen shots showing identification of patients and example of e-mail

86. 86 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC9B: Example Electronically Contacting Patient to Review Test Results

87. 87 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC9C: Electronic Care Management Support Electronic care management support for three clinically important conditions to 1.Communicate with disease/care managers about patient needs 2.Provide Web-based educational modules for patient self-management 1 point Scoring – 4 items = 100% – 3 items = 50% – 2 items = 25% – 0-1 items = 0% Data source – Screen shots showing electronic communication about care management – Screen shots or links to educational modules

88. 88 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC 9C: Example Electronic Care Management Support

89. 89 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Example PPC 9C: Diabetes Education Web-sites for Patient Self-Management

90. 90 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 What is the PPC-PCMH application and survey process?

91. 91 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Recognition Process Practices may use the Survey Tool to self-assess before submitting to NCQA Recognition is based on: – Responses in Web-based Survey Tool – Supporting documentation attached to Survey Tool Element specifies type of documentation – Reports Reports from EHR, registry, practice management & billing systems – Documentation of processes Policies and procedures, protocols – Records or files NCQA’s Medical Record Review Workbook Screen shots from EHR

92. 92 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Who is Recognized? NCQA Recognizes practices that meet the criteria described by the endorsed principles of the Patient-Centered Medical Home NCQA defines a practice as a physician or physicians practicing together at a single geographic location Recognition is at the practice-site level

93. 93 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 NCQA’s Interactive Survey System (ISS) ISS is a Web-based application program The practice uses ISS (Survey Tool) for: – Entering responses to each factor for each element – Attaching documents and providing text to support the responses

94. 94 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Steps for the Physician/Practice 1.Review program information 2.Participate in a standards workshop (See www.ncqa.org/rptraining.aspx) 3.Obtain a Survey Tool 4.Participate in a WebEx ISS demonstration of the Survey Tool 5.Use Survey Tool to self-assess current performance 6.Submit completed application, agreements, fee, and results to NCQA when ready 7.Receive final Recognition decision and Level in 30 – 60 days

95. 95 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC-PCMH Survey Process 1.NCQA receives Survey Tool 2.NCQA evaluates Survey Tool Responses, documentation, and explanations Practice may be contacted for clarifications 3.On-site audit - 5% of practices 4.Final decision and status determined 5.Report results with Level 1, 2, or 3 Recognition posted on NCQA Web site Not passed - not reported 6.PPC-PCMH certificate and recognition packet 7.Practice achieving Level 1 or 2 can do add-on survey within the 3 year recognition time period

96. 96 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 Results: Impact of Program Better chronic-care management programs Greater attention to patient compliance Improved patient outreach – Patient reminders, increased screenings – Educational materials Increased data collection and reporting Significant adoption and use of patient registries Measurement + Rewards = Improvement!

97. 97 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 NCQA Contact Information Contact NCQA Customer Support to: Acquire standards documents, application materials, and survey tools Questions about your user ID, password, access 1-888-275-7585 Visit NCQA Web Site to: View Frequently Asked Questions View Recognition Programs Training Schedule Submit to questions to ppc-pcmh@ncqa.orgppc-pcmh@ncqa.org Please use this e-mail box to: Ask about interpretation of standards or elements Submit application materials (physician workbook and application) Request registration for ISS Survey Tool demonstration (Web-ex)

98. 98 Physician Practice Connections ─ Patient-Centered Medical Home Standards Workshop 2009 PPC-PCMH Program Sponsors