Business Performance Services

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Release 11.0

Title page

2014 Clinical Quality Measures User’s Guide

Stages 1 and 2

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Copyright notice

Use of this documentation and related software is governed by a license agreement. This documentation and related software contain confidential, proprietary, and trade secret information of McKesson Corporation and/or one of its subsidiaries, and is protected under United States and international copyright and other intellectual property laws. Use, disclosure, reproduction, modification, distribution, or storage in a retrieval system in any form or by any means is prohibited without the prior express written permission of McKesson Corporation and/or one of its subsidiaries. This documentation and related software is subject to change without notice.

Publication date

July 2014

Product

Practice Partner, Release 11.0

Corporate address

McKesson Business Performance Services 5995 Windward Parkway

Alpharetta, GA 30005

Trademarks

Practice Partner® is a registered trademark of McKesson Corporation and/or one of its subsidiaries.

All other product and company names may be trademarks or registered trademarks of their respective companies.

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Table of Contents

Chapter 4 - Configuring the Clinical Quality Measures Report . . . 21

Chapter 5 - Building and Configuring the EHR Application . . . 25

Adding List Item Names and List Items. . . 30

Adding Clinical Element Names . . . 32

Adding clinical element names to templates . . . 33

Adding Health Maintenance Names . . . 36

Adding health maintenance procedure names to health maintenance templates. 37 Adding laboratory data test names . . . 40

Adding laboratory data test names to laboratory templates . . . 41

Adding order names . . . 42

Adding order names to order trees . . . 43

Appendix A - Diagnosis and Procedure Codes for Clinical Quality Measures . . . 45

Children Who Have Dental Decay or Cavities (CMS number 0075 v2) . . . 45

Functional Status Assessment for Complex Chronic Conditions (CMS number 0090 v3) 48 Use of Appropriate Medications for Asthma (Pediatric Core) (NQF 0036) (CMS number 0126 v2) . . . 52

Colorectal Cancer Screening (NQF 0034) (CMS number 0130 v2) . . . 52

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List of Figures

List of Figures

Figure 1 Login screen . . . 8

Figure 2 Clinical Quality Reporting screen . . . 9

Figure 3 Quality Measure Document screen . . . 10

Figure 4 Log Viewer screen. . . 11

Figure 5 Preview screen . . . 13

Figure 6 Reports screen . . . 14

Figure 7 Clinical Quality Measures Report example . . . 19

Figure 8 Report Settings screen . . . 21

Figure 9 Report Settings screen, with alternate name for the Asthma Control Test element . . . 23

Figure 10 List Names Select screen . . . 30

Figure 11 New List Name screen . . . 30

Figure 12 List Names Select screen . . . 31

Figure 13 List Items View screen . . . 31

Figure 14 List Item screen . . . 32

Figure 15 Clinical Element Names Select screen . . . . 32

Figure 16 Clinical Elements Maintenance screen . . . . 33

Figure 17 Flow/Lab/Clinical Templates screen . . . 34

Figure 18 Flow/Lab Templates screen . . . 34

Figure 19 Select Clinical Element Name screen . . . 35

Figure 20 Flow/Lab Templates screen . . . 35

Figure 21 Vital Sign Names Select screen . . . 36

Figure 22 Health Maintenance Procedure Name <New> screen . . . 36

Figure 23 Health Maintenance Templates screen. . . 37

Figure 24 Health Maintenance Template <Edit> screen . . . 38

Figure 25 Health Maintenance Procedures screen . . . 38

Figure 26 HM Procedure Rules <New> screen . . . 39

Figure 27 Health Maintenance Template <Edit> screen . . . 40

Figure 28 Lab Test Names screen . . . 40

Figure 29 Laboratory Test <New> screen . . . 41

Figure 30 Order Names Select screen . . . 42

Figure 31 Order Name <New> screen . . . 42

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Chapter 1 - Introduction

This guide offers step-by-step instructions on how to install, run, and configure the Practice Partner Clinical Quality Report for meaningful use. The Clinical Quality Measures report was created to help eligible professionals (EPs), hospitals, and critical access hospitals with their responses to particular measures required to qualify for meaningful use incentive payments.

This guide includes the following chapters.

See the following guides for information on the requirements for the entry of clinical information that is necessary to populate the report, as well as information regarding the Meaningful Use Stage 1 and Stage 2 objectives and measures.

• Practice Partner EHR Meaningful Use Stage 1 Guide - Configuration and End User Training • Practice Partner EHR Meaningful Use Stage 2 Guide - Configuration and End User Training

2014 and Beyond

Product Documentation

You can find the Practice Partner documentation referenced in this guide and the latest product documentation located on BPS Central.

Chapter Description

Installing the Clinical Quality Measures Report This chapter explains how to install the Clinical Quality Reporting tool and update your Clinical Quality Reporting tool components.

Running and Printing the Clinical Quality Measures Report

This chapter explains how to run and print the reports.

Configuring the Clinical Quality Measures Report

This chapter explains how to change the values for the elements that print on the Clinical Quality Measures report to correspond to the values your practice is using.

If you are a... Then access the user manuals here...

customer https://socialkb.mckesson.com/partner-central/ documentation

VAR https://socialkb.mckesson.com/var-central/ practice%20partner

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Chapter 2 - Installing the Clinical Quality

Measures Report

This chapter explains how to install or upgrade from a previous version of the Clinical Quality Measures report.

In this chapter

This chapter contains the following topics.

Topic See page

Installing the Clinical Quality Reporting Tool 4

Installation Notes 4

Upgrade Instructions 6

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Installing the Clinical Quality Reporting Tool

Installation Notes

Make sure that the version number of the Clinical Quality Reporting tool you are about to install exactly matches the version number of your Practice Partner server. For example, if you are using Practice Partner 11.0, you must install the Clinical Quality Reporting tool for 11.0.

The Clinical Quality Reporting tool is developed and configured to be run on the 32-bit version of Microsoft Office/Access. The 64-bit version of Microsoft Office is not supported. If your Practice Partner server is running the 64-bit edition of Microsoft Office, you must to uninstall it, install the 32-bit version of Microsoft Access, and then install the Clinical Quality Reporting tool.

Install the Clinical Quality Reporting tool on the Practice Partner server or a client workstation. If your site uses c-tree server, longer extraction times may occur if you install the tool on a client workstation.

NOTE: If you wish to install the Clinical Quality Reporting tool on a client workstation, contact Practice Partner Support for assistance.

To install the Clinical Quality Reporting tool:

1. Refer to the following table for your first step.

2. If you don’t have Microsoft Access Runtime 2010 installed on your machine, the installer will install it for you using the default location.

Do you have a Practice Partner - Server CD?

Then...

Yes insert the CD into your server or

workstation’s CD-ROM drive. The License Agreement screen appears.

If the License Agreement screen does not appear, complete the following steps.

a. On the taskbar, click the Start

button, and then click Run. The Run dialog box displays.

b. Enter d:\Clinical Quality Reporting\Clinical Quality Reporting v11.0.7571.msi in

Open, where d:\ is the drive letter the CD-ROM drive.

c. Click the OK button.

No Copy the downloaded Clinical Quality

Reporting .exe file to your Practice Partner

server or workstation and double-click the .exe file.

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Chapter 2 - Installing the Clinical Quality Measures Report Installation Notes

4. Select the I accept the terms in the License Agreement check box to indicate that you accept the agreement. Click the Print button to print the agreement.

5. Click the Install button. The Clinical Quality Reporting Setup screen displays the installation status.

After successfully installing the tool, the Setup Wizard Complete screen appears. It displays the name and the location of the log file that is created after the installation is complete. If the installation was not successful, you can check the log file to see why it failed.

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Upgrade Instructions

Installation Notes

Run the CQM report for your 2011 measures (that is, the measures supported in Practice Partner 9.5.2) and retain copies of your existing CQM reports before upgrading. The CQM Report for Practice Partner 11.0 supports the new 2014 CQM measures. After upgrading, you will not be able to generate the report for 2011 measures.

To retain copies of your existing reports, you must archive the following files prior to updating the Practice Partner Clinical Quality Reporting tool.

• PP Clinical Quality Reporting.accdb • Cqm_Settings.accdb

• TMP_*.accdb (archive ALL files that start with TMP and end with .accdb) These files are located in your ppart folder (typically p:\ppart).

Install the Clinical Quality Reporting tool on the Practice Partner server or a client workstation. If your site uses c-tree server, longer extraction times may occur if you install the tool on a client workstation.

To upgrade the Clinical Quality Reporting tool from a previous version:

1. Upgrade your server to Practice Partner 11.0. For procedural steps, see the Practice Partner Upgrade and Configuration Guide.

2. Upgrade your client workstation to Practice Partner 11.0. For procedural steps, see the Practice Partner Upgrade and Configuration Guide.

3. Run a new installation of the Clinical Quality Reporting tool. For procedural steps, see “To install the Clinical Quality Reporting tool:” on page 4.

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Chapter 3 - Running and Printing the Clinical

Quality Measures Report

This chapter explains how to run and print the Clinical Quality Measures report.

In this chapter

This chapter contains the following topics.

Topic See page

Running the Clinical Quality Measures report 8 Printing the Clinical Quality Measures report 15 Fields and Buttons on the Clinical Quality Reporting screen 16

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Running the Clinical Quality Measures report

RxNorm codes are required for measures that include medication lists as a part of their criteria. The first time you log in, a data file containing medications and their RxNorm codes will be downloaded and automatically imported into the Clinical Quality Reporting tool. The data file will be used to link your patients’ medications to RxNorm codes for reporting purposes.

The clinical data extraction process will determine if recently extracted data can be reused for the selected measures. If data can be reused, you can select to reuse the data or extract new data. Reusing data from the previous extraction date can save time when generating the report.

However changes made in Practice Partner since the previous extraction date will not be reflected in the measures’ scores.

To run the Clinical Quality Measures report:

1. Click Start > All Programs > McKesson > Practice Partner > Clinical Quality Reporting. The Login screen appears.

2. Enter your Practice Partner user ID and password in the User ID and Password fields.

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Chapter 3 - Running and Printing the Clinical Quality Measures Report Running the Clinical Quality Measures report

3. Click the OK button. The Clinical Quality Reporting screen appears.

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4. Optionally, click the ? icon next to a measure to view the Quality Measure Document screen that contains all the CMS requirements for the measure.

Figure 3. Quality Measure Document screen

5. In the Measures area, select the check boxes for the clinical quality measures you want to include in the report.

6. In the Extract area, choose the desired settings for the patient clinical data that will be retrieved out of your Practice Partner database.

a. Enter the dates for which you want to extract patient clinical data in the Extract From Date

and Extract To Date fields, or click the calendar to select the desired time period.

b. Leave the Automatically Summarize check box selected if you want the Clinical Quality Reporting tool to automatically summarize patient clinical data after extracting it from the Practice Partner database. Clear the check box to disable this functionality.

c. Click the Extract Data button to start the extraction process. If any recently extracted data can be reused, the Reuse Extracted Data message appears.

Click the... To...

Yes button reuse the data.

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The Log Viewer screen appears, displaying the progress of the data extraction.

Figure 4. Log Viewer screen

5. After the data extraction, click the Close button to close the Log Viewer screen.

6. In the Summarize area, enter the dates for which you want to run the report in the Report

From Date and Report To Date fields, or click the calendar to select the desired time period.

7. Click the Summarize Data button to summarize the extracted data based on the time range you selected for the report. You do not need to summarize data if you did not change the

Report From or Report To dates after the original extraction was completed and the

Automatically Summarize check box was selected.

8. In the Report area, choose the desired sort option for the report:

Select the... If you want to generate a...

All Providers Combined option button single list of the selected clinical quality

measures for all providers in your database.

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9. Optional:Click the Settings button to open the Report Settings screen and configure the report. For more information, see “Configuring the Clinical Quality Measures Report” on page 21.

10. Optional:Click the Export button to create a data file in any of the following formats:

- QRDA1 XML - QRDA3 XML - PDF

- MS Word - MS Excel

Click the desired format, enter the name of the output file, and click the Save button. By default, output files are saved in your Practice Partner database folder (typically p:\ppart), but you can select another location, if required.

By Provider option button report for a specific provider or a

selection of providers.

Click the Providers button to open the Choose Providers screen. Use this screen to choose the desired providers or provider groups.

To select providers:

a. Select the appropriate check boxes, or click the Select All

button to run a report for all available providers.

b. Click the Close button when you have made your selections.

Tip: Use the search area at the bottom of the Choose Providers screen to locate the provider you want to include in the report.

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11. Click the Preview button to preview to open the Preview screen and subsequently print the output of the report.

Figure 5. Preview screen

12. On the Preview screen, click the Numerator/Denominator link to view a list of the patients that meet the criteria of the respective clinical quality measure. The IPP, Denom, Numerator,

Exclusion, and Exception option buttons indicate whether the patient was included in the

calculation of the:

- initial patient population, - numerator,

- denominator, or both numerator and denominator, or

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- are an exception to respective clinical quality measure, due to an allowable reason for nonperformance of a quality measure.

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Chapter 3 - Running and Printing the Clinical Quality Measures Report Printing the Clinical Quality Measures report

Printing the Clinical Quality Measures report

Print the Clinical Quality Measures report from the Preview or Print Preview screens.

To print the report from the Preview screen:

1. With the Preview screen open, select File > Print. 2. Use the following table to determine your next step:

The report is printed.

To print the report from the Print Preview screen:

1. With the Print Preview screen open, click the Print button on the toolbar. The Print screen appears.

2. Select a printer.

3. Click the OK button. The report is printed.

Select the... To...

Print option select a printer. The Print screen

appears.

a. Select a printer. b. Click the OK button.

Quick Print option send the report directly to your default

printer without making changes to the print settings.

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Fields and Buttons on the Clinical Quality

Reporting screen

Fields/Buttons Description

Measures Select the meaningful use measure(s) you want to include in the report. Selecting these will gather and report a total population for the category, the number in that population that qualified for the meaningful use measure, and the percentage that qualified.

Click the Help buttons (to the right of the measure check boxes) to open files which explain the initial patient population, numerator, denominator, exclusions, and exceptions (if applicable) for each of the measures.

Extract

Extract From Date/Extract To Date Enter the range of dates for which you want to extract patient clinical data or click the calendar to select the desired dates. Practice Partner will extract data pertaining only to the clinical quality measures selected in the

Measures area.

Data Last Extracted This field reflects the date and time when the report data was last extracted from the Practice Partner database. Automatically Summarize Select this check box if you want the Clinical Quality

Reporting tool to automatically summarize patient clinical data after extracting it from the Practice Partner database. This check box is selected by default.

Extract Data Click this button to start the data extraction process. Note that this process can take a considerable amount of time depending on the size of your database.

Summarize

Report From Date/Report To Date Enter the range of dates for which you want to run the report or click the calendar to select the desired dates. Use these fields to narrow the date range of the report if you selected a broader range for the extract data in the

Extract area. This way you can run multiple reports with

different report parameters (providers, report period, and so on) without having to re-extract patient clinical data every time you change the report parameters. Make sure to enter a report date range that falls within the extract date range.

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Chapter 3 - Running and Printing the Clinical Quality Measures Report Fields and Buttons on the Clinical Quality Reporting screen

Data Last Summarized This field reflects the date and time when the report data was last summarized.

Summarize Data Click this button to summarize the extracted data based on the time range you selected for the report.

Report

All Providers Combined Select this option button to run the report for all providers. By Provider Select this option button to run the report for (a) selected provider(s) or provider group(s). The report will be broken out for each of the selected provider/provider group. For example, if you are running the report for five providers, there will be five denominator/numerator sets for each measure.

Providers Click this button to open the Choose Providers screen. Use this screen to select the provider(s) or provider group(s) for which you want to run the report. Select the appropriate check boxes or click the Select All button to include all providers in the report.

Use the search area at the bottom of the screen to locate the provider you want to include in the report.

Settings Click this button to open the Report Settings screen. Use this screen to change the values for the elements that print on the report. For more information, see “Configuring the Clinical Quality Measures Report” on page 21.

Export Click this button to create a data file in any of the following formats.

Option Select this option to create...

QRDA1 XML an individual-patient-level quality report using the QRDA format. The individual report(s) will be added to a .zip file and saved in the default location.

QRDA3 XML an aggregate quality report using the QRDA format. The report will be added to a .zip file and saved in the default location.

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Preview Click this button to run the report. Exit Click this button to close the screen.

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Chapter 3 - Running and Printing the Clinical Quality Measures Report Report Example

Report Example

The following diagram illustrates an example of the printed Clinical Quality Measure report.

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Chapter 4 - Configuring the Clinical Quality

Measures Report

You can change the values for the elements that are included on the Clinical Quality Measures report to correspond to the values your practice is using.

To configure the Clinical Quality Measures Report:

1. Click the Settings button on the Clinical Quality Reporting screen. The Report Settings screen appears.

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• condition diagnosis codes • encounters • medications • notes • prenatal • procedure codes • vaccines

Note: Values must be delimited by commas and surrounded individually by single quotes.

You can enter only ONE name for the following elements:

• allergy names (with the exception of the Pneumococcal Vaccine and Influenza Vaccine Allergy names)

• clinical element names • Health Maintenance names • lab names

• procedure names • vital signs

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Chapter 4 - Configuring the Clinical Quality Measures Report

Note: Do not surround names by quotes.

Figure 9. Report Settings screen, with alternate name for the Asthma Control Test element

3. Click the Reset to Default button if you want to restore the default value for the selected item. 4. Click the Close button to apply the changes you made to the report settings.

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Chapter 5 - Building and Configuring the EHR

Application

IMPORTANT: Calculations for the 11 Clinical Quality Measures described in this chapter have

been tested in McKesson’s internal test environments and appear to function correctly. This chapter will be updated as more information is obtained for the remainder of the Clinical Quality Measures. Some known defects exist in some of the measures and are being investigated. Resolutions will be released in the form of patches as and when available.

The following table provides information on the elements that need to be built in order to print on the Clinical Quality Measures report.

NOTE: Any clinical element listed below can be entered using any name of your choice as long as it is linked to the specific LOINC or SNOMED code listed.

Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan (NQF 0418) (CMS number 0002 v3)

Numerator Value of Positive or Negative in clinical element field ADULT

DEPRESSION SCREEN or ADOLESCENT DEPRESSION SCREEN

entered on same date as that of the visit.

If Positive, then the patient must have either of the following: a suicide

risk assessment (procedure linked to SNOMED code 225337009) within a day OR an anti-depressant prescription (in the current medication list).

Denominator All patients 12 years of age and older with a clinical encounter type of

Office Visit.

Exclusion Patients who already have been diagnosed with Major Depression and/ or Bipolar Disorder.

Build and Configuration

Clinical elements: ADULT DEPRESSION SCREEN linked to LOINC code 73832-8 and ADOLESCENT DEPRESSION SCREEN linked to LOINC code 73831-0.

List item: DEPRESSION SCREENING RESULTS with a drop-down list with the following values: Negative and Positive. Negative linked to

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Denominator All patients with one or more clinical encounter during the measurement period with a completed order for REFERRAL TO PROVIDER.

Order name: REFERRAL TO PROVIDER and clinical element:

Consultant Report linked to SNOMED code 371530004.

Functional Status Assessment for Hip Replacement (CMS number 0056 v2)

Numerator Any value in clinical element field Func Stat Joint Replacement

entered on the same date as that of the office visit.

Denominator All patients 18 years and older, who have had a total hip arthroplasty (THA) within 180 days before or 180 days after the reporting period with at least one clinical encounter type of Office Visit and

• either 180 days before the THA OR

• between 60 days and 180 days after THA.

NOTE: CPT procedure code 27130 (Primary THA Procedure) is required in the Problem List.

Clinical element: Func Stat Joint Replacement linked to LOINC code 71955-9.

Functional Status Assessment for Knee Replacement (CMS number 0066 v2)

Numerator Any value in clinical element field Func Stat Joint Replacement

entered on the same date as that of the office visit.

Denominator All patients 18 years and older, who have had a total knee arthroplasty (TKA) within 180 days before or 180 days after the reporting period with at least one clinical encounter type of Office Visit and

• either 180 days before the TKA OR

• between 60 days and 180 days after TKA.

NOTE: CPT procedure code 27447 (Primary TKA Procedure) is required in the Problem List.

Clinical element: Func Stat Joint Replacement linked to LOINC code 71955-9.

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Chapter 5 - Building and Configuring the EHR Application

Children Who Have Dental Decay or Cavities (CMS number 0075 v2)

Numerator A diagnosis of Dental Caries on the Problem List dated before the end of the measurement period, and did not end before the start of the measurement period.

For a list of Dental Caries diagnosis codes that count for this measure, see “Children Who Have Dental Decay or Cavities (CMS number 0075 v2)” on page 45.

Denominator All patients 20 years old and younger at the start of the measurement period, who have a clinical encounter during the measurement period. Build and

Configuration

None.

Functional Status Assessment for Complex Chronic Conditions (CMS number 0090 v3)

Numerator Any value in the clinical element field Func Stat Heart Failure with the same date as both clinical encounters.

Denominator All patients 65 years or older at the start of the measurement period who have two clinical encounters during the measurement period, as well as an active diagnosis of Heart Failure.

To see a list of Heart Failure diagnosis codes that count for this measure, see “Functional Status Assessment for Complex Chronic Conditions (CMS number 0090 v3)” on page 48.

Exclusions All patients in the denominator who have on their Problem Lists one of the following diagnoses that is active any time before the end of the measurement period. • Severe Dementia OR • Cancer Build and Configuration

Clinical Element: Func Stat Heart Failure linked to LOINC code 71938-5.

Use of Appropriate Medications for Asthma (Pediatric Core) (NQF 0036) (CMS number 0126 v2)

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Denominator All patients ages 5-64 who have an active diagnosis of Persistent Asthma on their Problem Lists and who have a clinical encounter during the measurement period.

To see a list of Persistent Asthma diagnosis codes that count for this measure, see “Use of Appropriate Medications for Asthma (Pediatric Core) (NQF 0036) (CMS number 0126 v2)” on page 52.

NOTE: On the report, the metric is broken down into the following age ranges: 5-64, 5-11, 12-18, 19-50, and 51-64.

Exclusions All patients in the denominator who have on their Problem Lists one of the following active diagnoses, that starts before the end of the measurement period and that does not end before the start of the measurement period.

• Chronic Obstructive Pulmonary Disease • Emphysema

• Cystic Fibrosis

• Acute Respiratory Failure Build and

Configuration

None.

Pneumonia Vaccination Status for Older Adults (NQF 0043) (CMS number 0127 v2)

Numerator At least one of the following on the Health Maintenance List before the end of the measurement period:

• Pneumococcal vaccine (for example, PNEUMOCOCCAL POLY or

PNEUMOVAX)with Status = X or E

Denominator All patients 65 years and older at the start of the measurement period, who have had a clinical encounter during the measurement period. Build and

Configuration

Health Maintenance: Any pneumococcal vaccine name (for example,

PNEUMOCOCCAL POLY or PNEUMOVAX), linked to code 33 and

code type CVX.

Use of Appropriate Medications for Asthma (Pediatric Core) (NQF 0036) (CMS number 0126 v2)

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Chapter 5 - Building and Configuring the EHR Application

Colorectal Cancer Screening (NQF 0034) (CMS number 0130 v2)

Numerator One of the following procedures on the problem list:

• Colonoscopy in the 10 years prior to the end of the measurement period

• Flexible Sigmoidoscopy in the 5 years prior to the end of the measurement period

To see a list of Colonoscopy and Flexible Sigmoidoscopy procedure codes that count for this measure, see “Colorectal Cancer Screening (NQF 0034) (CMS number 0130 v2)” on page 52.

Denominator All patients 50-75 years old at the start of the measurement period, who have had a clinical encounter anytime in the two years before the end of the measurement period.

Exclusions Patients in the denominator who have had one of the following before the end of the measurement period.

• An active, inactive, or resolved diagnosis for Malignant Neoplasm of Colon

• Total Colectomy Build and

Configuration

None.

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (NQF 0028) (CMS number 0138 v2)

Numerator The patient is assessed as a smoker in Vitals, and

• the clinical element Tobacco Intervention check box is selected (value Y)

OR

• a medication is prescribed for tobacco use cessation in the 24 months prior to the end of the measurement period.

Denominator Patients who are 18 years or older who have at least two clinical encounters during the measurement period.

Exceptions An assessment for tobacco use was not done for medical reasons, or the patient received a diagnosis of Limited Life Expectancy before the end of the measurement period.

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Adding List Item Names and List Items

To add a list item name:

1. In Patient Records, select Maintenance > Templates > List Maintenance. The List Names Select screen appears.

Figure 10. List Names Select screen

2. Click the New button. The New List Name screen appears.

Figure 11. New List Name screen

3. Enter the new list name in the Name field.

Denominator All patients 65 years and older at the start of the measurement period, who have had a clinical encounter during the measurement period. Exceptions A risk category assessment is not done for medical reasons. For

example, the Problem List has an entry for Patient Not Ambulatory

before the end of the measurement period, and that problem does not end before the start of the measurement period.

Clinical element: Falls Screening linked to LOINC code 73830-2.

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Chapter 5 - Building and Configuring the EHR Application Adding List Item Names and List Items

5. Select the added list item name.

Figure 12. List Names Select screen

6. Click the Edit button. The List Items View screen appears.

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7. Click the New button. The List Item screen appears.

Figure 14. List Item screen

8. Enter the list item’s name in the Name field.

9. Optional Link the list item to a SNOMED or LOINC code.

10. Click the OK button.

11. Repeat steps 7 - 10 until you have added all list items.

Adding Clinical Element Names

To add a clinical element name:

1. In Patient Records, select Maintenance > Templates > Clinical Element Names. The Clinical Element Names Select screen appears.

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Chapter 5 - Building and Configuring the EHR Application Adding clinical element names to templates

2. Click the New button. The Clinical Elements Maintenance screen appears.

Figure 16. Clinical Elements Maintenance screen

3. Fill in the fields on this screen. 4. Click the Apply button. 5. Click the OK button.

Adding clinical element names to templates

To add a clinical element name to an existing template:

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3. Click the OK button. The Flow/Lab/Clinical Templatesscreen appears.

Figure 17. Flow/Lab/Clinical Templatesscreen

4. Select the Clinical Elements option.

5. Select an existing clinical elements template from the list. 6. Click the Edit button. The Flow/Lab Templates screen appears.

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Chapter 5 - Building and Configuring the EHR Application Adding clinical element names to templates

7. Click the plus button (+) next to the Clinical Elements label (in the Template Category tree). The Select Clinical Element Name screen appears.

Figure 19. Select Clinical Element Name screen

8. Enter the clinical element’s name in the Search field. 9. Click the Search button.

10. Select the clinical element name in the list.

11. Click the OK button. The clinical element name is added to the Template Items list (on the Flow/Lab Templates screen).

12. Use the arrow buttons (on the right-hand side of the screen) to move the clinical element name to the place you want it to appear in the template.

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13. Click the OK button to save your changes and close the screen. 14. Click the Close button to close the Flow/Lab/Clinical Templatesscreen.

Adding Health Maintenance Names

To add a health maintenance name:

1. In Patient Records, select Maintenance > Templates > Health Maintenance Names. The Health Maintenance Procedure Names screen appears.

Figure 21. Vital Sign Names Select screen

2. Click the New button. The Health Maintenance Procedure Name <New> screen appears.

Figure 22. Health Maintenance Procedure Name <New> screen

3. Enter the name of the health maintenance procedure that you want to add in the HM Name

field.

4. Fill in the rest of the fields on this screen.

5. Optional Click the More button to open the Health Maintenance More Info screen. Use this

screen to add default information (such as vaccination, dose, route, and lot) about the health maintenance procedure name. Click the OK button to save the information and close the screen.

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Chapter 5 - Building and Configuring the EHR Application Adding health maintenance procedure names to health

Adding health maintenance procedure names to health

maintenance templates

To add health maintenance procedure names to health maintenance templates:

1. In Patient Records, select Maintenance > Templates > Health Maintenance Templates. The Provider/Practice Selection screen appears.

2. Select the provider or practice whose templates you want to edit, or leave the Provider ID and

Practice ID fields blank to add a universal template (that is, templates that can by used by all

providers).

3. Click the OK button. The Health Maintenance Templates screen appears.

Figure 23. Health Maintenance Templates screen

4. Select the health maintenance template that you want to edit.

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Figure 24. Health Maintenance Template <Edit> screen

6. Click the New Proc button. The Health Maintenance Procedures screen appears. 7. Select the health maintenance procedure name that you want to add to the template.

Figure 25. Health Maintenance Procedures screen

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Chapter 5 - Building and Configuring the EHR Application Adding health maintenance procedure names to health

Figure 26. HM Procedure Rules <New> screen

9. Fill in the fields on this screen.

10. Click the OK button to save the information and close the screen. The selected procedure is added to the Health Maintenance Template <Edit> screen.

(46)

Figure 27. Health Maintenance Template <Edit> screen

11. Click the OK button to close the screen. The Health Maintenance Templates screen appears. 12. Click the Close button to close the screen.

Adding laboratory data test names

To add a laboratory data test name:

1. Select Maintenance > Templates > Lab Data Test Names. The Lab Test Names screen appears.

(47)

Chapter 5 - Building and Configuring the EHR Application Adding laboratory data test names to laboratory templates

Figure 29. Laboratory Test <New> screen

3. Enter the name of the lab test that you want to add in the Test Name field. 4. Fill in the rest of the fields on this screen.

5. Click the OK button to save your changes and close the screen.

Adding laboratory data test names to laboratory templates

To add a lab data test name to a laboratory template:

1. In Patient Records, select Maintenance > Templates > Flow/Lab/Clinical Templates. The Provider/Practice Selection screen appears.

Practice ID fields blank to add a universal template.

3. Click the OK button. The Flow/Lab/Clinical Templatesscreen appears. 4. Use the following table to determine your next step:

5. Select the template that you want to edit in the list.

6. Click the Edit button. The Flow/Lab Templates screen appears.

7. Click the plus sign (+) next to the Laboratory Data label (in the Template Category tree). The

Select the... To add a lab data test name to an existing...

Lab Review option button lab review template.

(48)

11. Click the OK button to save your changes and close the screen.

Adding order names

To add an order name:

1. In Patient Records, select Maintenance > Templates > Order Templates > Order Names. The Order Names Select screen appears.

Figure 30. Order Names Select screen

(49)

Chapter 5 - Building and Configuring the EHR Application Adding order names to order trees

3. Select an order type option (Single Order, Visible Order Set, or Hidden Order Set). 4. Enter the name of the order that you want to add in the Order Name field.

5. Fill in the rest of the fields on this screen.

6. Click the OK button save your changes and close the screen. 7. Click the Close button to close the Order Names Select screen.

Adding order names to order trees

McKesson recommends adding new order names to your order tree(s) to provide quick access to the tests used most frequently.

To add an order name to an order tree:

1. Select Maintenance > Templates > Order Templates > Order Trees. The Provider / Practice Selection screen appears.

Practice ID fields blank to add a universal template (that is, templates that can by used by all

providers).

3. Click the OK button. The Order Tree screen appears.

(50)

- To move the order up or down in the order hierarchy, click the up arrow or down arrow buttons.

The first level in the order hierarchy, denoted by the plus sign (+) to the left of the level, should always be “Order Tree.” All orders in the hierarchy should be subordinate to “Order Tree.” 8. Click the OK button to save your changes and close the screen.

(51)

Appendix A - Diagnosis and Procedure Codes for

Clinical Quality Measures

This appendix provides lists of diagnosis or procedure codes that count for the following measures.

Children Who Have Dental Decay or Cavities (CMS number 0075

v2)

Topic See page

Children Who Have Dental Decay or Cavities (CMS number 0075 v2) 45 Functional Status Assessment for Complex Chronic Conditions (CMS number

0090 v3)

48

Use of Appropriate Medications for Asthma (Pediatric Core) (NQF 0036) (CMS number 0126 v2)

52

Colorectal Cancer Screening (NQF 0034) (CMS number 0130 v2) 52

Code System Code Description

ICD10CM K02.3 Arrested dental caries

ICD10CM K02.51 Dental caries on pit and fissure surface limited to enamel

ICD10CM K02.52 Dental caries on pit and fissure surface penetrating into dentin

ICD10CM K02.53 Dental caries on pit and fissure surface penetrating into pulp

ICD10CM K02.61 Dental caries on smooth surface limited to enamel ICD10CM K02.62 Dental caries on smooth surface penetrating into

dentin

ICD10CM K02.63 Dental caries on smooth surface penetrating into pulp

ICD10CM K02.7 Dental root caries

ICD10CM K02.9 Dental caries, unspecified ICD9CM 521.00 Dental caries, unspecified

(52)

ICD9CM 521.06 Dental caries pit and fissure ICD9CM 521.07 Dental caries of smooth surface ICD9CM 521.08 Dental caries of root surface

ICD9CM 521.09 Other dental caries

SNOMEDCT 109564008 Dental caries associated with enamel hypomineralization (disorder)

SNOMEDCT 109566005 Dental caries associated with enamel hypoplasia (disorder)

SNOMEDCT 109568006 Dental caries secondary to developmental defects of tooth structure (disorder)

SNOMEDCT 109569003 Dental caries secondary to acquired defects of tooth structure (disorder)

SNOMEDCT 109571003 Primary dental caries, indeterminate origin (disorder) SNOMEDCT 109581004 Caries of infancy associated with bottle feeding

(disorder)

SNOMEDCT 15733007 Incipient enamel caries (disorder) SNOMEDCT 163152009 On examination - dental caries (disorder) SNOMEDCT 196298000 Acute dentine dental caries (disorder) SNOMEDCT 196299008 Chronic dentine dental caries (disorder) SNOMEDCT 196301001 Acute enamel dental caries (disorder) SNOMEDCT 196302008 Chronic enamel dental caries (disorder) SNOMEDCT 196305005 Odontoclasia (disorder)

SNOMEDCT 234976000 Rampant dental caries (disorder) SNOMEDCT 30512007 Cementum caries (disorder)

SNOMEDCT 442231009 Caries involving multiple surfaces of tooth (disorder) SNOMEDCT 442551007 Dental caries extending into dentine (disorder) SNOMEDCT 5170009 Complex dental caries (disorder)

SNOMEDCT 80353004 Enamel caries (disorder) SNOMEDCT 80753001 Arrested dental caries (disorder) SNOMEDCT 80967001 Dental caries (disorder)

SNOMEDCT 95246007 Salivary dysfunction caries secondary to aging (disorder)

SNOMEDCT 95247003 Salivary dysfunction caries secondary to medication (disorder)

(53)

Appendix A - Diagnosis and Procedure Codes for Clinical Quality Measures Children Who Have Dental Decay or Cavities (CMS

SNOMEDCT 95249000 Salivary dysfunction dental caries (disorder) SNOMEDCT 95252008 Secondary dental caries associated with failed or

defective dental restoration (disorder)

SNOMEDCT 95253003 Secondary dental caries associated with local or systemic factors (disorder)

SNOMEDCT 95254009 Secondary dental caries (disorder)

(54)

Functional Status Assessment for Complex Chronic Conditions

(CMS number 0090 v3)

Code System Code Description

ICD10CM I11.0 Hypertensive heart disease with heart failure ICD10CM I13.0 Hypertensive heart and chronic kidney disease with

heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease ICD10CM I13.2 Hypertensive heart and chronic kidney disease with

heart failure and with stage 5 chronic kidney disease, or end stage renal disease

ICD10CM I50.1 Left ventricular failure

ICD10CM I50.20 Unspecified systolic (congestive) heart failure ICD10CM I50.21 Acute systolic (congestive) heart failure ICD10CM I50.22 Chronic systolic (congestive) heart failure

ICD10CM I50.23 Acute on chronic systolic (congestive) heart failure ICD10CM I50.30 Unspecified diastolic (congestive) heart failure ICD10CM I50.31 Acute diastolic (congestive) heart failure ICD10CM I50.32 Chronic diastolic (congestive) heart failure

ICD10CM I50.33 Acute on chronic diastolic (congestive) heart failure ICD10CM I50.40 Unspecified combined systolic (congestive) and

diastolic (congestive) heart failure

ICD10CM I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure

ICD10CM I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure

ICD10CM I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure

ICD10CM I50.9 Heart failure, unspecified

ICD9CM 402.01 Malignant hypertensive heart disease with heart failure ICD9CM 402.11 Benign hypertensive heart disease with heart failure ICD9CM 402.91 Unspecified hypertensive heart disease with heart

failure

ICD9CM 404.01 Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified ICD9CM 404.03 Hypertensive heart and chronic kidney disease,

(55)

Appendix A - Diagnosis and Procedure Codes for Clinical Quality Measures Functional Status Assessment for Complex Chronic

ICD9CM 404.11 Hypertensive heart and chronic kidney disease, benign, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified ICD9CM 404.13 Hypertensive heart and chronic kidney disease,

benign, with heart failure and chronic kidney disease stage V or end stage renal disease

ICD9CM 404.91 Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified ICD9CM 404.93 Hypertensive heart and chronic kidney disease,

unspecified, with heart failure and chronic kidney disease stage V or end stage renal disease ICD9CM 428.0 Congestive heart failure, unspecified

ICD9CM 428.1 Left heart failure

ICD9CM 428.20 Systolic heart failure, unspecified ICD9CM 428.21 Acute systolic heart failure ICD9CM 428.22 Chronic systolic heart failure

ICD9CM 428.23 Acute on chronic systolic heart failure ICD9CM 428.30 Diastolic heart failure, unspecified ICD9CM 428.31 Acute diastolic heart failure ICD9CM 428.32 Chronic diastolic heart failure

ICD9CM 428.33 Acute on chronic diastolic heart failure ICD9CM 428.40 Combined systolic and diastolic heart failure,

unspecified

ICD9CM 428.41 Acute combined systolic and diastolic heart failure ICD9CM 428.42 Chronic combined systolic and diastolic heart failure ICD9CM 428.43 Acute on chronic combined systolic and diastolic heart

failure

ICD9CM 428.9 Heart failure, unspecified

SNOMEDCT 10091002 High output heart failure (disorder) SNOMEDCT 10335000 Chronic right-sided heart failure (disorder)

(56)

SNOMEDCT 194779001 Hypertensive heart and renal disease with (congestive) heart failure (disorder)

SNOMEDCT 194781004 Hypertensive heart and renal disease with both (congestive) heart failure and renal failure (disorder) SNOMEDCT 195111005 Decompensated cardiac failure (disorder)

SNOMEDCT 195112003 Compensated cardiac failure (disorder) SNOMEDCT 195114002 Acute left ventricular failure (disorder) SNOMEDCT 206586007 Congenital cardiac failure (disorder)

SNOMEDCT 233924009 Heart failure as a complication of care (disorder) SNOMEDCT 25544003 Low output heart failure (disorder)

SNOMEDCT 277639002 Sepsis-associated right ventricular failure (disorder) SNOMEDCT 314206003 Refractory heart failure (disorder)

SNOMEDCT 359617009 Acute right-sided heart failure (disorder) SNOMEDCT 359620001 Acute right heart failure (disorder) SNOMEDCT 364006 Acute left-sided heart failure (disorder) SNOMEDCT 367363000 Right ventricular failure (disorder) SNOMEDCT 410431009 Cardiorespiratory failure (disorder) SNOMEDCT 417996009 Systolic heart failure (disorder) SNOMEDCT 418304008 Diastolic heart failure (disorder) SNOMEDCT 42343007 Congestive heart failure (disorder)

SNOMEDCT 424404003 Decompensated chronic heart failure (disorder) SNOMEDCT 426012001 Right heart failure due to pulmonary hypertension

(disorder)

SNOMEDCT 426263006 Congestive heart failure due to left ventricular systolic dysfunction (disorder)

SNOMEDCT 426611007 Congestive heart failure due to valvular disease (disorder)

SNOMEDCT 43736008 Rheumatic left ventricular failure (disorder) SNOMEDCT 441481004 Chronic systolic heart failure (disorder) SNOMEDCT 441530006 Chronic diastolic heart failure (disorder)

SNOMEDCT 44313006 Right heart failure secondary to left heart failure (disorder)

SNOMEDCT 46113002 Hypertensive heart failure (disorder) SNOMEDCT 48447003 Chronic heart failure (disorder)

(57)

Appendix A - Diagnosis and Procedure Codes for Clinical Quality Measures Functional Status Assessment for Complex Chronic

SNOMEDCT 5148006 Hypertensive heart disease with congestive heart failure (disorder)

SNOMEDCT 5375005 Chronic left-sided congestive heart failure (disorder) SNOMEDCT 56675007 Acute heart failure (disorder)

SNOMEDCT 60856006 Cardiac insufficiency following cardiac surgery (disorder)

SNOMEDCT 66989003 Chronic right-sided congestive heart failure (disorder) SNOMEDCT 74960003 Acute left-sided congestive heart failure (disorder) SNOMEDCT 77737007 Benign hypertensive heart disease with congestive

heart failure (disorder)

SNOMEDCT 80479009 Acute right-sided congestive heart failure (disorder) SNOMEDCT 82523003 Congestive rheumatic heart failure (disorder)

SNOMEDCT 83105008 Malignant hypertensive heart disease with congestive heart failure (disorder)

SNOMEDCT 84114007 Heart failure (disorder) SNOMEDCT 85232009 Left heart failure (disorder)

SNOMEDCT 88805009 Chronic congestive heart failure (disorder) SNOMEDCT 90727007 Pleural effusion due to congestive heart failure

(disorder)

SNOMEDCT 92506005 Biventricular congestive heart failure (disorder)

(58)

Use of Appropriate Medications for Asthma (Pediatric Core) (NQF

0036) (CMS number 0126 v2)

Colorectal Cancer Screening (NQF 0034) (CMS number 0130 v2)

Code System Code Description

ICD10CM J45.30 Mild persistent asthma, uncomplicated

ICD10CM J45.31 Mild persistent asthma with (acute) exacerbation ICD10CM J45.32 Mild persistent asthma with status asthmaticus ICD10CM J45.40 Moderate persistent asthma, uncomplicated

ICD10CM J45.41 Moderate persistent asthma with (acute) exacerbation ICD10CM J45.42 Moderate persistent asthma with status asthmaticus ICD10CM J45.50 Severe persistent asthma, uncomplicated

ICD10CM J45.51 Severe persistent asthma with (acute) exacerbation ICD10CM J45.52 Severe persistent asthma with status asthmaticus SNOMEDCT 426656000 Severe persistent asthma (disorder)

SNOMEDCT 426979002 Mild persistent asthma (disorder) SNOMEDCT 427295004 Moderate persistent asthma (disorder)

Code System Code Description

Colonoscopy

CPT 44388 Colonoscopy through stoma; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)

CPT 44389 Colonoscopy through stoma; with biopsy, single or multiple

CPT 44390 Colonoscopy through stoma; with removal of foreign body

CPT 44391 Colonoscopy through stoma; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma

CPT 44392 Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery

CPT 44393 Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique CPT 44394 Colonoscopy through stoma; with removal of tumor(s),

(59)

Appendix A - Diagnosis and Procedure Codes for Clinical Quality Measures Colorectal Cancer Screening (NQF 0034) (CMS

CPT 44397 Colonoscopy through stoma; with transendoscopic stent placement (includes predilation)

CPT 45355 Colonoscopy, rigid or flexible, transabdominal via colotomy, single or multiple

CPT 45378 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon

decompression (separate procedure)

CPT 45379 Colonoscopy, flexible, proximal to splenic flexure; with removal of foreign body

CPT 45380 Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple

CPT 45381 Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance CPT 45382 Colonoscopy, flexible, proximal to splenic flexure; with

control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)

CPT 45383 Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique

CPT 45384 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery

CPT 45385 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

CPT 45386 Colonoscopy, flexible, proximal to splenic flexure; with dilation by balloon, 1 or more strictures

CPT 45387 Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic stent placement (includes predilation) CPT 45391 Colonoscopy, flexible, proximal to splenic flexure; with

endoscopic ultrasound examination

(60)

SNOMEDCT 12350003 Colonoscopy with rigid sigmoidoscope through colotomy (procedure)

SNOMEDCT 174158000 Open colonoscopy (procedure)

SNOMEDCT 174184006 Diagnostic endoscopic examination on colon (procedure)

SNOMEDCT 235150006 Total colonoscopy (procedure) SNOMEDCT 235151005 Limited colonoscopy (procedure)

SNOMEDCT 25732003 Fiberoptic colonoscopy with biopsy (procedure) SNOMEDCT 303587008 Therapeutic colonoscopy (procedure)

SNOMEDCT 310634005 Check colonoscopy (procedure) SNOMEDCT 34264006 Intraoperative colonoscopy (procedure) SNOMEDCT 367535003 Fiberoptic colonoscopy (procedure)

SNOMEDCT 418714002 Virtual computed tomography colonoscopy (procedure) SNOMEDCT 427459009 Diagnostic endoscopic examination of colonic pouch

and biopsy of colonic pouch using colonoscope (procedure)

SNOMEDCT 443998000 Colonoscopy through colostomy with endoscopic biopsy of colon (procedure)

SNOMEDCT 444783004 Screening colonoscopy (procedure)

SNOMEDCT 446521004 Colonoscopy and excision of mucosa of colon (procedure)

SNOMEDCT 446745002 Colonoscopy and biopsy of colon (procedure) SNOMEDCT 447021001 Colonoscopy and tattooing (procedure) SNOMEDCT 73761001 Colonoscopy (procedure)

SNOMEDCT 8180007 Fiberoptic colonoscopy through colostomy (procedure)

Flexible Sigmoidoscopy

CPT 45330 Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)

CPT 45331 Sigmoidoscopy, flexible; with biopsy, single or multiple CPT 45332 Sigmoidoscopy, flexible; with removal of foreign body CPT 45333 Sigmoidoscopy, flexible; with removal of tumor(s),

polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery

CPT 45334 Sigmoidoscopy, flexible; with control of bleeding (eg,

(61)

Appendix A - Diagnosis and Procedure Codes for Clinical Quality Measures Colorectal Cancer Screening (NQF 0034) (CMS

CPT 45335 Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance

CPT 45337 Sigmoidoscopy, flexible; with decompression of volvulus, any method

CPT 45338 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique CPT 45339 Sigmoidoscopy, flexible; with ablation of tumor(s),

polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique CPT 45340 Sigmoidoscopy, flexible; with dilation by balloon, 1 or

more strictures

CPT 45341 Sigmoidoscopy, flexible; with endoscopic ultrasound examination

CPT 45342 Sigmoidoscopy, flexible; with transendoscopic

ultrasound guided intramural or transmural fine needle aspiration/biopsy(s)

CPT 45345 Sigmoidoscopy, flexible; with transendoscopic stent placement (includes predilation)

HCPCS G0104 COLORECTAL CANCER SCREENING; FLEXIBLE

SIGMOIDOSCOPY

SNOMEDCT 112870002 Flexible fiberoptic sigmoidoscopy for removal of foreign body (procedure)

SNOMEDCT 396226005 Flexible fiberoptic sigmoidoscopy with biopsy (procedure)

SNOMEDCT 425634007 Diagnostic endoscopic examination of lower bowel and sampling for bacterial overgrowth using fiberoptic sigmoidoscope (procedure)

SNOMEDCT 44441009 Flexible fiberoptic sigmoidoscopy (procedure)

(62)

(63)

Glossary

A

acute inpatient encounters

Clinical encounters of the Hospital Visit type.

D

denominator

The individuals or events for which the expected process and/or outcome should occur. The denominator is calculated by adding all that meet denominator criteria.

E

exceptions

Allowable reasons for the nonperformance of a clinical quality measure for patients that meet the denominator criteria and do not meet the numerator criteria. Denominator exceptions are the valid reasons for patients who are included in the denominator population but for whom a process or outcome of care does not occur.

exclusions

The individual characteristics that cause the expected process and/or outcome to be inappropriate for an individual or an event specified in the denominator. Exclusions are calculated for all patients who meet denominator criteria and who do not meet numerator criteria. Measures with multiple numerators apply the same exclusions to each numerator.

initial patient population (IPP)

The group of patients the performance measure is designed to address.

M

measure score

The measure score is the percentage of the objective that was achieved. The measure score value on the report is the numerator value divided by the denominator value expressed as a percentage.

measurement period

The date range selected for the report by entering values in the Report From Date (measurement start date) and the Report To Date (measurement end date) fields.

(64)

O

outpatient encounters

Clinical encounters of the following types: Office Visit, Home Visit.

Q

Quality Reporting Document Architecture (QRDA)

A standard document format for the exchange of clinical quality measure (CQM) data.

QRDA1

An individual-patient-level quality report using the QRDA format. Each report contains quality data for one patient for one or more quality measures, where the data elements in the report are defined by the particular measure(s) being reported on.

QRDA3

An aggregate quality report using the QRDA format. Each report contains calculated summary data for one or more measures for a specified population of patients over a specific period of time.

R

RxNorm codes

A normalized naming system for generic and branded drugs. RxNorm codes are linked to drug vocabularies commonly used in pharmacy management and drug interaction software, including Medi-Span. By providing links between these vocabularies, RxNorm can mediate messages between systems not using the same software and vocabulary.

U

unique patients

The total number of individual patients for whom there is at least one clinical encounter record for the provider forwhom the measure is being calculated and the patient was seen within the specified date range. For example, if a provider saw patient A once and saw patient B twice within the date range, the total for the number of unique patients would equal 2.

(65)

Index

Index

A

adding

clinical element names 32

clinical element names to templates 33

health maintenance names 36

health maintenance procedure names to health maintenance templates 37

list item names 30

list items 30

automatically summarize option 16

B

building

clinical elements 25

buttons 16

C

clinical elements building 25

Clinical Quality Measures Report changing report settings 17

exporting 17

fields and buttons 16

previewing 18

running 7

selecting providers 17

Clinical Quality Measures report configuring 21

Clinical Quality Reporting tool installing 4

upgrading 6

configuring

Clinical Quality Measures report 21

D

MS Excel 17 MS Word17 PDF 17 QRDA1 XML 17 QRDA3 XML 17 extract dates

data last extracted 16

selecting 16 extracting data 16

F

fields 16 Flow/Lab/Clinical templates 33

H

health maintenance names 36

health maintenance procedure names 37

health maintenance templates 37

I

installation instructions 4

installing

Clinical Quality Reporting tool 4

L

list item names 30

list items 30

M

measure score 57 measurement period 57

N

numerator 57

P

(66)

R

report dates

data last summarized 17

selecting 16

report example 19

report settings 21

S

screens

Clinical Element Names Select screen 32

Clinical Elements Maintenance screen 33

Flow/Lab Templates screen 34

Flow/Lab/Clinical Templates screen 34, 41

Health Maintenance More Info screen 36

Health Maintenance Procedure Name New screen 36

Health Maintenance Procedure Names screen 36

Health Maintenance Procedures screen 38

Health Maintenance Template Edit screen 37, 39

Health Maintenance Templates screen 37

HM Procedure Rules New screen 38

List Item screen 32

List Items View screen 31

List Names Select screen 30, 31

Login screen 8

New List Name screen 30

Preview screen 15

Print Preview screen 15

Quality Measure Document 10

Select Clinical Element Name screen 35

settings 17, 21

summarizing report data 17

T

templates

Flow/Lab/Clinical 33

health maintenance 37

health maintenance name36

list names 30

U

unique patients 58

upgrade instructions 6

upgrading