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

2. 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.

3. 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.

4. 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, 2013. 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.

5. 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.

6. 5 Tobacco Use Screening CY 2013 4,890 6,191 36,071 36,722 5,536 5,563 5,729 5,739 0000 47,055 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.

7. 6 Tobacco Cessation Intervention CY 2013 248 386 4,640 5,565 486 596 163 789 0000 4,434 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.

8. 7 Blood Pressure Screening CY 2013 5,654 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.

9. 8 Follow-Up Blood Pressure Screening CY 2013 307 326 2,843 2,900 111 112 272 0000 1,049 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

10. 9 Follow-Up Blood Pressure Screening CY 2013 261 411 3,384 3,865 124 128 51 92 0000 1,711 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

11. 10 Diabetes: No A1c Test Frequency CY 2013 64 676 494 3,842 28 587 139 1,062 -- 60 281 5,606 Not Reported

12. 11 Diabetes: A1c Test Frequency >=1 CY 2013 612 676 3,348 3,842 928 1,062 859 1,064 60 5,325 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.

13. 12 Diabetes: A1c Test Frequency >/=2 CY 2013 331 676 2,124 3,842 383 587 557 1,062 44 60 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.

14. 13 Diabetes: A1c Ideal Control <7.0% CY 2013 283 676 1,495 3,842 208 587 379 1,062 2,021 5,606 22 60 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. 14 Diabetes: A1c Control 7.0% through 7.99% CY 2013 93 676 632 3,842 92 587 188 1,062 1,153 5,606 14 60 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. 15 Diabetes: A1c Control <8.0% CY 2013 376 676 2,127 3,842 300 587 567 1,062 36 60 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.

17. 16 Diabetes: A1c Control 8.0% through 9% CY 2013 68 676 446 3,842 92 587 160 1,062 9 60 776 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.

18. 17 Diabetes: A1c Poor Control >9.0% CY 2013 232 676 775 3,842 195 587 335 1,062 15 60 1,375 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

19. 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.

20. 19 Diabetes: Lipid Panel Testing Frequency CY 2013 249 676 2,913 3,842 446 587 755 1,062 50 60 4,867 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.

21. 20 Diabetes: LDL Control CY 2013 249 676 1,515 3,842 226 587 436 1,062 28 60 2,861 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.

22. 21 Diabetes: No LDL CY 2013 196 676 929 3,842 141 587 285 1,062 10 60 739 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. 22 Diabetes: Ideal Blood Pressure Control CY 2013 249 676 1,376 3,842 178 587 458 1,062 23 60 2,336 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.

24. 23 Diabetes: Blood Pressure Control CY 2013 249 676 2,619 3,842 380 587 760 1,062 46 60 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.

25. 24 Hypertension: Blood Pressure Control CY 2013 504 1,008 4,271 7,263 511 916 1,474 1,594 41 78 4,740 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.

26. 25 Hyper-Cholesterolemia LDL Control CY 2013 276 531 563 1,567 161 415 93 221 0000 616 1,888 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. 26 Hyper-Cholesterolemia No LDL 2013 196 531 557 1,567 131 415 33 221 0000 236 1,888 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.

28. 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

29. 28 IVD: Aspirin Use CY 2013 12 36 732 890 108 128 54 182 0000 774 910 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. 29 IVD: Lipid Panel Testing Frequency CY 2013 36 694 890 99 128 108 182 0000 756 910 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. 30 IVD: LDL Control CY 2013 15 36 424 890 62 128 72 182 0000 496 910 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.

32. 31 IVD: No LDL CY 2013 7 36 211 890 29 128 69 182 0000 161 910 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. 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

34. 33 IVD: Blood Pressure Control CY 2013 21 36 594 890 84 128 162 182 617 910 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