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  • 1. e-MDs East Central User Training Webinar October 25, 2012 1:00 pm ETOperator: Good afternoon, ladies and gentlemen, and thank you for waiting. Welcome to the e-MDs East Central User Training Webinar. All lines have been placed on listen-only mode, and the floor will be opened for your questions and comments periodically throughout the presentation. If you would like to utilize the Chat function, please enter your questions throughout the presentation. We will try to get through as many as we can. Without further ado, it is my pleasure to turn the floor over to your host, Ms. Fran Otte. Ms. Otte, the floor is yours.Fran Otte: Thank you. Hello and welcome. My name is Fran Otte, and I am the Senior Quality Improvement Facilitator at Telegen, the Iowa QIO. There are 23 Quality Improvement Organizations funded by CMS who are hosting this program today, and we will be joined by Robin Bowles from e-MDs to provide us with this hour of training. For those of you who are not familiar with the QIOs, every three years, CMS implements a cycle of work known as the Scope of Work, and this is our tenth one. So Quality Improvement Organizations are charged with assisting the healthcare community improve the safety, effectiveness, and efficiency of patient care. These no-cost consulting services help to meet CMSs goal for better health for individuals, better health for populations and communities, and affordable care through improvement. We are working with your communities, addressing immunizations, cancer screenings, as well as the cardiovascular health. We assist with better understanding and utilization of your electronic health record, and particularly capturing data and reporting that will lead to better population health. If you would like more information on the current initiatives of your states QIO, you can utilize the Chat button, and I will forward their contact information to you. I want to thank e-MDs for their commitment and assistance to help the QIOs and practices by providing these free user training opportunities. 1
  • 2. Now, one more thing I wanted to talk about is 2012 PQRS data submission. We have two months left to boost data in your clinics and capture the 80% of the patients who meet each measure. You may want to start running reports now to see how you are looking on at least three of those measures. You can then address any deficits and follow up with patients in order to better provide patient care and better population management and be successful PQRS submitters. If you dont already have an IACs account, you will want to get started on that right away, as it takes several weeks for approval. Work with the QIO and the QualityNet help desk. And remember, you have until February 28, 2013, to submit your 2012 PQRS data through your electronic health record. And with that, I would like to now turn the rest of the webinar over to Robin Bowles, who will educate us on e-MDs reports and so much more. Thank you, Robin.Robin Bowles: Thank you. Good afternoon, everyone. Ive got a whole bunch of questions, so were just going to start right at the top. I received a question about Measure Number 237, so were going to go ahead and look at the dashboard. Now, the thing I want to remind everybody about, and I recognize that you all need the 2012 dashboard. Its due to be released either late next week or the very beginning of the following week. I was hoping to have one today to show you, but that was not possible. So just know that thats coming. And when youre running a PQRS dashboard, it is the 2011. Most of the measures, or the criteria for the measures, havent changed, but there are some measures that wont be on there, and you just have to look to see. So were going to take a look at Measure Number 237 and see what kind of data has been generated. And well start at the beginning of the year and go to todays date. And Im going to run this for--well just go ahead and run it for one provider. Its going to take its time. And then well see if 237 was--yes, that was a last years measure as well. So were going to go look and see what weve got. We have three eligible for the denominator and none meeting numerator. So in order to deal with this, I need to go and see who should have met the measure, but they didnt. Carrie Coughlin should have met the measure, but she didnt, and apparently shes been here several times. This particular measure requires two visits to even be in the denominator, but apparently were not taking blood pressure during those visits. So if I want to go back and look to see, "Why am I not doing that?" I can actually pull up her chart and see, "Are we forgetting to put them in the note?" Because it does require, you cant just take the vitals up here in 2
  • 3. the vitals module. They do have to be brought into the note, because thequery is in the Vitals Flow Sheet.So looking at her visits, no vitals. I suspect theyre all like that, becauseshes kind of one of my favorites that I use. Heres another one, novitals. So thats why shes not meeting the measure.To correctly, to get a patient to meet the measure, they have to have twovisits within the period. And what I want to show you guys now is theEducation Departments been working furiously on documents to help youguys with this, so Im going to go ahead and show you some of the onesthat weve already got ready. And theyll actually be out, theyre workingon the PQRS Resource Center now. So Im hoping that maybe it will beup the very, very first of next week, maybe even by tomorrow. But letme go ahead and show you what they look like.So its going to take you through the logic required for the denominator,and it will tell you the definition of the population that its trying to queryfor. Its going to tell you that all the patients on this report should be 18years of age or older, and they have to have a documented diagnosis ofhypertension at any time before or during the measurement period. Soas long as they have an active diagnosis of hypertension in their currentproblems, they should qualify for that portion of the patient population.But to actually be in the denominator, they have to meet the initialcriteria, so theyve got to have hypertension in their current problem, andthey need to be at least 18 years of age. The additional criteria that putsthem in the denominator is that they have two face-to-face visits with theeligible professional during the measurement period. And these are thecodes that will qualify them for that. And then it gives you the list ofcodes for hypertension.To be in the numerator, theyve got to have documentation of theirsystolic and diastolic blood pressure. There are no exclusions for thisreport.And then theres a section at the end of each KB article that tells you howto meet the measure using e-MDs. So its going to take you throughsome workflows.This one talks about recording the blood pressure in the vitals moduleand then adding it to the visit note. You can also add the vitals directlyto the visit note. So some people, because of their workflow, the layoutof their clinic, will take the vitals outside of the note and bring them intothe note. Others will just go ahead and start the note and put the vitalsin there. So either way, as long as those vitals are brought into the visitnote, your patient will be fine. 3
  • 4. Lets see here. The vitals do not populate that Vitals Flow Sheet untilthey are brought into the note. So blood pressures taken outside of anote are not going to qualify. I just thought that was important and thatthat was something that you guys might need to know. So thats whatthese KB articles are going to look like and how theyre going to work.So that was the first question that I had. And hopefully, thats going toanswer the question.Another really interesting question that I got had to do with whether ornot the PQRS measures can be satisfied if we have a rule running thatskind of helping us with our PQRS. Can that rule be satisfied with flowsheet content? And yes, it absolutely can.So I want to show you guys some of the things that Ive done. In myRule Manager, what I did was I took my mammogram rule, which is righthere, and I added that rule. And there was a new box that was addedback in 70, I think, and it says, "Use the result to satisfy the rule." So inother words, the rules typically, or at least in the past, they could only besatisfied by an order. We now have the ability to satisfy that rule by aresult. So I checked this box, and then I indicated what the test codesare that satisfy that rule, and then in my flow sheet, in my PreventiveCare Flow Sheet, I have linked my mammogram field data element to the77057, which is the preventive mammogram code. And its the code thatmy clinic uses. If youre not ordering it, it doesnt really matter what youlink it to as long as its one of the codes that satisfy that PQRS measure.So let me give you a scenario. If I am a specialist--or no, lets see. Im aprimary care doctor, and I have patients that I dont order theirmammograms because their OB-GYN does that. They do their annualexam, and they order their mammograms. However, I always get a copyof that result.So the workflow would be, if I can set my rule up like this and then I putin my Preventive Care Flow Sheet, I put that mammogram field and link itup to that 77057, that rule is going to be satisfied by that mammogramdocumentation. And Ill show you what I mean.So once youve done that, and youre running your rule like that, if youhave a patient, and I actually do, I was checking one earlier to see if Ihad this scenario already set up, and I did. I think it was this patientright here. No, it was Carrie Coughlin.So if I look in her rules, the mammogram rule is not there for her. So itsbeen satisfied, and its not in her pending. And so she meets all thecriteria, so why isnt she in here? The reason is because in my PreventiveCare Flow Sheet, right here, she had a current mammogram result. Andthats the reason why her rule isnt showing, because her rule has beensatisfied by this result in this field. 4
  • 5. The other document that youre going to be seeing out on the SupportCenter very quickly thats going to help you with this--Im actually goingto go through some of those workflows today, but I want you to see it.Its called the PQRS Numerator Methodology Document. And what itsgoing to do is its going to show you, step-by-step, click-by-clickinstructions with screen shots, all of the ways that you can satisfy anumerator.For instance, if I want to know, "How can I satisfy it by ordering a CPT ina visit note? How can I attach a CPT to a template item so its capturedin the visit note?" "What do they mean when they say adding amedication or an active medication? What does that mean?" Thatsadding or prescribing or refilling a medication, and this is how that workflows. An immunization order, documentation of an immunization in aflow sheet.The one that most people dont know about is this Linking CPT Codes toFlow Sheet Data Elements. And so that particular workflow is actuallydocumented in here, and Im going to show you that document. Andthen Im going to go through it and show you what Im talking about.So heres what it actually looks like. So its going to take you, step bystep, how to access your flow sheets module, how to access the field anddata element that you need to link a PPT code to. The Report Guide willtell you what codes are required. Once you select the code you want tolink your flow sheet field to, then youll be able to follow this documentand do that. But Im going to go through it today while were on thewebinar.Under your Run menu, you have your flow sheets, and then if it comesup and it asks about wanting to do results, were not going to do thatright now. Im going to go ahead and pull up the flow sheet (inaudible)that appear. Now, our Product Department has done a lot of work onthis flow sheet. If youll notice, theres a whole lot of new fields in here.Ive applied the new content update thats our on our Support Centernow. Its called the Template Flow Sheet Update, and its going tocontain some really critical items for your PQRS reporting and yourMeaningful Use reporting.Notice how almost everything in this flow sheet has got a code linked toit. Where it says, "Linked to," it says, "Lab." So if I want to link a codeso that my reporting will pick it up--we didnt link everything, because insome instances, there are so many codes that could be used, and we didnot want to make that decision for you. So instead, we supplied you withthe education to be able to link those flow sheet fields to the proper codethat you use in your clinic. 5
  • 6. For the example today, because we do have an osteoporosis PQRS measure, Im going to link my DEXA to the DEXA code that I use in my clinic when I order a DEXA, or the code thats required by the PQRS measure to satisfy the numerator. So Im going to edit this, and the data element is right here. This is what actually captures the data. So thats where were going to link the code. So Im going to actually use my Search, and Im going to edit this DEXA data element. And right now it says its going to have text in it. Now, I can change that to say I want a date and time in there, or I can just leave it as text, because theres going to be a date already associated with this item, because whenever I get that DEXA result, Im going to add that DEXA result to the Preventive Care Flow Sheet with the date that I reviewed it. Next, Im going to associate--its a misnomer. It says Associated Master Lab Code. What that means is CPT code. So Im going to find the CPT code that is required for this particular measure, and then Im going to go out and Im going to link it to this flow sheet. And if I go up here, I can search for it first, so I can type D for DEXA, and I can see I dont have a DEXA field, so Im going to create one. It creates the short name, the description, and the flow sheet element. All Ive got to do now is link that CPT code. So all of this is automatic when you click New. Im going to go to my CPT Reference Menu, and Im going to find my DEXA code. And Im going to pick the one that is tied to the PQRS measure, or the one that I order, and then Im going to attach it. And I do believe this is the one thats most commonly ordered, so were going to attach it like that and Save. Thats all there is to linking a flow sheet data element in a flow sheet. And now, when I result that DEXA, my osteoporosis measure for PQRS, will know that Ive done that and recognize that in the numerator, provided they meet the criteria for that. So you can add all kinds of things here, anything that meets the criteria. If its not appropriate for the Preventive Care Flow Sheet, you certainly can create any flow sheet that you want if its easier for you to document that. I want to show you one other flow sheet thats been added to content with that content update, and its called Smoking Status. So this is now part of your content. Note that its got a really nice layout, but its already linked, its already linked to the codes that are required for Meaningful Use, and its already linked to all the codes that are required for PQRS. So let me show you how to use this.Lorraine Wanham: Hi, this is Lorraine. Can I stop you for a second?Robin Bowles: You sure can. 6
  • 7. Lorraine Wanham: We have a question. When linking the CPT, do you need to place a checkmark in the code, or just select it as you did in the example?Robin Bowles: No. Just select it as I showed in the example. That checkmark puts it on your Favorites List. Thats all that does.Lorraine Wanham: Okay. Another question as well. Can you use many different codes to satisfy a rule, or must you select only one?Robin Bowles: It only needs one, and so when youre linking to a flow sheet, the issue is you cant link it to more than one CPT code. So I can show you what Ive done. We had a mini-user conference here at e-MDs not very long ago, and what I did was I created a flu shot field for both Medicare and non- Medicare so that I could link the Medicare one to the Medicare code, and the non-Medicare to the normal influenza code thats used. So you can create mimicked fields, but link them to different data elements. But thats just going to require that you add another one in here. So if I was going to do that, I would create a new field, and thats a new field and a new data element. Im going to call this Influenza, and Im going to say Medicare. So I know that this one is where I put my Medicare patients. And then I want, lets see, we can put a date and time in there. It can be whatever that data type is. And then Im going to go down here and Im going to find what the flu shot code is for Medicare. And see, Ive already done this once before, so Im hoping its going to let me do it again. Yes, no, it wont. And thats how I would link it and then save it. I cant do it because Ive done it again, I applied this update, and so now it wont let me do it again because its gone. So thats how you do it. You just put your flu shots in there. So if you use multiple codes, youre going to have to create multiple flow sheet fields. And if you dont like that idea, then just let the order satisfy it. So you have different options. Anything else, Lorraine?Lorraine Wanham: Hi. There was one other question. If you get a moment, if we can go back to hypertension documentation. Could you run through an example of how you would use the reports for that and how you would go through the hypertension process?Robin Bowles: Didnt I do that? Okay.Lorraine Wanham: Its just, it popped up in the Chat that they wanted more of an explanation, so somebody missed something. Okay, thanks. 7
  • 8. Robin Bowles: All right, and let me go back. Im going to go back to that, because Ive already started this other thing. So if I add Carrie Coughlin, if I add the Smoking Status flow sheet to her chart. And this is how its structured. Corinne did a really nice job on this. What she did, here are your MU codes, here are your PQRS codes, here are your interventions for MU, here are your interventions for PQRS, and then heres the additional tobacco history that most doctors like to document. Once you document something in there, its a done deal and the report can capture it. The other thing that she did is in the Past Medical History Template right here, she actually attached that Preventive Care Flow Sheet to the Preventive Health Template, and its right here. So you can actually access and document preventive care information that patients give you. And if I did it today, I just click New Date. But if Im asking my patient, "When was your last pneumococcal shot?" and they tell me, "I got my pneumonia shot in 2007," I would have to click New Date and then I would put 2007 in there, get as close to the date as I possibly could. Now I have a new date and I can go right here to the pneumococcal vaccination and document that right there. But I want to change that to 2007. There. Okay? And I had that field duplicated because I had already created it. And now I can actually select that data and bring it into my preventive care, like that. The other thing that I can do is--sorry about that--I think, actually, the way that shes done this is that you dont have to add that old date. You can just put it here and then just document the date that it was done. There. Like that. So Im going to take those out. There.Fran Otte: Robin, theres another question about why you have to enter all this in the template and the flow sheet.Robin Bowles: You dont have to. Yes, you dont have to enter it in both places. Thats the whole point here, is I can either enter in a year, put it in that flow sheet, or I can use the template. So youve got choices. You cant use the Past Medical History--you cant use the left-hand side of the chart to document data that have to have a date associated with it. Thats the reason why weve made it so that you can access a flow sheet, get the data in there, and associate a date with it, because flow sheets have dates associated with them. Thats their very nature. Okay? So thats the reason why. If youve already been doing your preventive care in a template, you dont like the idea or you dont want to use the preventive template. Lets say Im already using a Past Medical History Template, and I like it just fine. I dont want to have to go to a whole different template to get to that flow sheet. You can add that flow sheet to any past Medical History Template you want to. So if you just take the template that you have, that youre using for past medical history, and you want to be able 8
  • 9. to access that Preventive Care Flow Sheet from that template, youre justgoing to go into Editor mode, and youre going to go to New, New ItemUnder, and youre going to create a flow sheet.And then right here Im going to type Preventive Care Flow Sheet. UnderGenerated Text, Im going to remove that, because I dont really wantthat necessarily to print in my notes. However, I could say PreventiveCare History. I could say something like that if I wanted that to print.And then I could hit my Enter so that that information drops to anotherline. If you dont want it to do that, you dont have to do it that way. SoIm going to drop to another line and put my caret in there.Next, Im going to go to the flow sheet and Im going to say, "Bring up asingle flow sheet." Which flow sheet do I want? Im going to click thisellipses right here, go find my Preventive Care Flow Sheet, and select it.And then Im going to say, "Okay, thats all youve got to do." And nowyou can add that flow sheet in any template you want, and then you cansequence it. You can put it wherever you want. So I want it up to thetop. I might have to push it a little ways at a time. And then now I canget to it from my Past Medical History Template.And if Im going to document information thats in there, I can check itand select it, and now its part of my Past Medical History. Now, I think itformats very nicely, so this is the date it was documented. One is thedate it was documented and one is the date that it was done. Okay?Any flow sheet can be amended like that, and you can attach CPT codesto them so they can capture dated information for your PQRS reporting.All right.Were going to do a visit for Carrie Coughlin because she needs to appearon our report. The very first thing I have to do is make sure, does shehave two visits within the reporting period? And shes got this one todayand shes got one on 10/5. Shes also got some in September.I need to make sure that she had a hypertension diagnosis. So again,Im going to look at her current problems and see if she hashypertension. And it doesnt look like she has a current hypertension.Hyperlipidemia, diabetes--there she is, theres her hypertension. Soweve got hypertension, she has the correct diagnosis. I dont have tobring it into a visit note. Thats not required.So Im going to go here and she could be in today for, she could becoming in today for a sore throat, and I would document my sore throat.But the main thing that its looking for is it wants to know, did I takesystolic and diastolic blood pressure values? So Im going to go aheadand Im going to put in her weight, and then Im going to put in her 9
  • 10. temperature, and Im going to put in her blood pressure. And then Imgoing to save. And thats all thats required for the report.And then I have to make sure that in my plan that I add an E&M code sothat the report can capture it, so Im going to go ahead and plug in a99214 in there. Normally, you would use your E&M code to do that. Andthats whats required for the report. Okay? And I dont know if thereport parameters changed for that report, but well give it a shot. Imnot scared. Well run our PQRS dashboard and see if she shows up onthere now.Now, we did not do blood pressure both times, but it just needs to bedocumented at one of the qualifying visits. So were going to go back.And she was the only one that hit our report. And there. And then Imjust going to run this for Dr. Kildeer this time, and were just going to runthat one measure. And now shes in there. Yay!So now I can see shes in there once, but she also has other qualifyingvisits because shes been seen more than twice this year. All right. Andthat was actually what I think the person that sent this question inbrought up. This is not--remember, this is the 2011. This is not theactual current 2012 measure. So as long as youve got patients that arehitting the report, if the number is not right on the 2011 report for thismeasure, dont worry about it, because the 2012, hopefully, will havecorrected that. Because I dont think that they should be in there morethan once. They should only qualify once. Okay.And I believe that was the question that I got. So youre right. It iscounting them more than once, so the 2011 reports not right. But aslong as youre getting a numerator for your patients that are in yourdenominator, thats what youre looking for. And then the 2012 reportshould not do that. And Im actually, Ill make sure Corinnes aware ofthat after we get off the phone. Because she can double-check to makesure the 2012 reports not calculating that same way.All right. I had a question about how to deal with the patients that arenot hitting the report. So Im going to go ahead and run that dashboard,and were going to take a look at a couple of different measures. Andwere going to look at, "How can I address those patients that should behitting the report, but theyre hitting my denominator, but theyre notgetting in my numerator, and I need to find out why that is?" And wehave to use the 2011 right now because we dont have the 2012 yet.I have been able to successfully use the registry processor for certainmeasures to be able to pull up data, just to make sure Im getting data.So were going to just run this for one doctor. Were going to run it forDr. Killdeer, but were going to run all the measures. Any questions atthis point, Lorraine? 10
  • 11. Lorraine Wanham: Hi. There are a few in the Chat function. Do you want me to read, or do you want to read them? Whatevers easier for you.Robin Bowles: Oh, lets see. Okay. "The 2012 report should also calculate the percentage of visits where blood pressure was reported. So it is correct that patients will appear for each visit as long as they had at least two visits." Okay, thank you, Sandra, I appreciate that. So the reports not broken. And, "When will the 2012 PQRS reports be available?" I addressed that at the beginning of the call. I believe its either going to be next week or the week after that. Thats as specific as I can get at this point. "The blood pressure measure requires that blood pressure be documented in every visit, not just one. It requires two visits." Yes, so thats what you said. Its going to count it every time. And I did not realize that, so thank you for that clarification. "Why is smoking broken out into MU and PQRS?" Because different codes are required for Meaningful Use than are required for PQRS. We were required to write specific descriptions for smoking statuses for Meaningful Use, and so we had to create custom codes for those specific codes. They dont match one-to-one with the PQRS descriptions, so thats why theres two different sets of codes. That was definitely not our choice. That came from CMS, and we just followed the rule. I also have a question about, "Is there an advantage to using a flow sheet versus the template?" The benefits to flow sheets, I think, number one, is theyre very easy to create, they can be tied to a code, they can have a date associated with them, no matter where theyre used. So even on the history side of the chart, I can tie a date to it. Thats the main advantage. Other than that, it really depends on the doctors workflow. Again, were talking about you need to make the software come to you. What your workflow is, thats what you want to use. But what weve done is weve just created more logic to make it easier for you guys to get the data. And then Ive got something that says, "The column date on the flow sheet was used to determine the measure logic," and that she was told putting the date in the field of the flow sheet would not calculate the correct date. And Im going to have to check with Corinne on that. Im not absolutely positive on that. Quite frankly, that was my understanding as well, that I had to put a new date in the flow sheet. But when she set these flow sheets up, she set them up to put a date in there. So thats why I kind of flipped there and said--so Im going to have to find out 11
  • 12. about that, and well get the information to the QIOs, and then they canget the information to you. Im going to have to check with her on that.Lets see. This documentation for PQRS will be available, it will beavailable next week on the Support Center. Youll have a new button outthere that says PQRS Resource Center. The Numerator MethodologyDocument, weve already sent to the QIOs, so your QIOs have thatdocument already, but it will be available on our Support Center alongwith the first 25 PQRS measures. We will be finishing the other 22 overthe next week. So its probably going to take us a week or two to finishup the other 20. But those first 25 were the ones needed by the QIOs.Theyre the most common ones being used by the providers using oursoftware, so we started with those and we got those out first.All right. So lets go ahead and look at how to manage the patients thatare not hitting your numerator. So, for instance, on this one right here,the Preventive Care and Screening, I have two patients out of four. Whyis that?The first thing Im going to look at is who are those patients that were inthe denominator but did not meet it? And so heres your "Not" page.Ive got these two patients that didnt get in the numerator and shouldhave been in there. They meet the age requirement, they meet all theother requirements. So why is it that they didnt?So at this point, Im going to take these two patients, and Im going to goback and look at their charts. Was it just that we forgot, we didntdocument their refusal? Could that perhaps be it? So Im going to belooking at those charts and finding out what we did not document.Now, for reports that do allow for either inclusion or exclusions becauseof a circumstance that may have prevented you from performing thataction on that patient, you have modifiers that have to be used with thePQRS codes, the 1P, 2P, 3P, and 8P. And so if thats a common scenariothat happens and you want those patients included, thats got to bedocumented.So for instance, this patient was one of the ones that should have hadone but didnt. So how can I get him to hit the report? If it is allowed asan exclusion, so Im going to go back into one of his notes, Im going togo down to the plan, and youve got a couple of different options here. Imyself think that if I have decided which measures Im going to reporton, I know the PQRS measures Im trying to hit. My recommendationwould be to add that information into either a Current and Future Orderstemplate or place a jump in here to a PQRI template and give yourself allthose codes. 12
  • 13. And so, for instance, on my immunizations, if they refused thatimmunization, its possible that I could add a refusal section here, or Icould build a refusal section, and I could include all my codes. And then Ican attach the correct modifier. So if Im going to build something likethat, Im going to go ahead and build something like Refusals. Andtheres actually one in here. I went and found it, and I copied it for adoctor yesterday.And then I can go and build the next level with all of the codes that Ineed for my refusal. So if they refused the pneumococcal, if they refusedtheir colonoscopy, I can record that with my Rules Manager, but itdoesnt document a code for me. So thats where, in order for the reportto capture it, Ive got to have a refusal code in there.Okay. And so if Im going to build something like that, and Im going tosay that they refused their influenza, and Im trying to remember whichones allow for that, and thats why these documents are so important foryou guys is that it will actually tell you whether you can use that or not.So Im going to go ahead and look at the influenza one, and Im going tobring it up on the screen so that we can check that out. All right.So heres the influenza. And as far as exclusions go--yes. If theyreallergic to the vaccine, that would exclude them from the report, meaningtheyll be excluded from the denominator and the numerator. So this onedoesnt really, it doesnt indicate that its going to allow that. This onehasnt been vetted yet, so Ive got to make some changes to it.So here are the--okay, the 4037 1P, 2P, and 3P. So if they had an allergyto it, and one of these codes is documented in their current problems,then that report will exclude them. If I document that they were refusedfor a medical reason because theyre allergic to it, Id rather do that thandocument that they have an allergy to one of the vaccine componentsand add that in their current problems. I can do it that way. So youhave two different things that you could possibly do here.Im going to go ahead and show you how to put that refusal code for amedical reason into your template. So were going to need a 4037F 1P.So under my refusals, Im just going to build 3P, influenza for medicalreasons. And I dont even have to really say why. And then what Imgoing to do is tie that code right here. And heres my 1P. And then Imgoing to say okay.So now, if they refused something, it becomes a whole lot easier for meto document that refusal and get that patient off of the report as a Not.Okay? See if Ive got any questions. That should have generated lots ofquestions. 13
  • 14. And Im not saying that you have to go back and correct yourdocumentation. The PQRS measures and the requirements for thosehave been out for a while, so the codes that were needed have been outthere for a while. So if you havent been adding them, then youre goingto have some patients that arent going to meet that.But I guess the point I was trying to make was its sometimes just aworkflow thing; somebodys not documenting something they should.Sometimes its missing content; its content that you need to add to makeit easy to get documented. So going back and looking at patients thatshould have been in the numerator that werent allows you to changeyour workflow or do whatever you need to do to make sure that you arecapturing that data.Lets see here. Let me go to the top. Okay. Okay. I think Ive got allthe questions now. So that basically should take that patient out of thereport now. Let me look at whats next here.And there was a question about whether or not the reports would showan 80% threshold. And I think you saw how the reports did for this year.Whether or not the new reports show that percentage or not, I dontknow that. I dont know that. I could calculate that manually fairlyeasily. I do know that because youre going to be submitting through aPQRS engine that was developed for QRDA, its going to, it will have thatcalculation in it. And the example that Ill give you is--and I had one outon my desktop earlier, but I dont think I still have it--the clinical qualitymeasures, when you created that electronic file. And let me just showyou all what that looks like, because I believe the new engine will lookvery similar to that.So if I run this, and then Im going to do my tobacco and my flu shot, Imgoing to do my breast cancer, and I want my colorectal cancer screening.To me, these are easy, low-hanging fruit for primary care. You alreadydo this anyway, so you might as well.So if I run this, and I can go down here, and then Im going to run it forthis year. I want to show you what this XML file looks like, because Iknow the new one will be very similar to this. It may not be--just so thatyou understand that it will have all that information in it.If I go out here and I look on my desktop, heres my QM file, and it lookslike this. But what youre going to do, you can go down and you can findthe measures pretty quickly. So here is Measure Number 13, thats yourhypertension. I have four eligible instances, one that meets theperformance instance, none excluded, and three that did not meet. Thereporting rate is 100% of the population, and the performance rate is25%. So QRDA requires a certain format, and I believe this is all the 14
  • 15. information that will be contained in that file that you upload to CMS.Hopefully, that answers that question.Oh, I hope I did not just close this session. All right. Lets see. I alreadyaddressed that one. There were some questions on the smoking report,and I went into a lot of detail on this last time. So there may be somenew folks on the call, so Im going to go in and repeat that.For Meaningful Use, the codes that are required are different for smokingstatus. Where most people are having trouble is getting the cessation tocount. And so youve got a couple of different options now. Numberone, most important, it must be done in the note. The cessation and thesmoking status have got to be dated information and documented.Thats one reason why that flow sheet was created, so you can use a flowsheet to do it, or you can do it in your notes. And lets say Im going touse, if you go down to the plan, and the Current and Future Orders Planhas this.Notice this is another change that was made with this new flow sheetcontent update. Referrals now it has an orange star, because thats youroutgoing transition of care. And here weve got smoking status, andthats the old one, but now you have a new one right here. Its got anorange star. And so if I document it here, its going to actually, thats allMeaningful Use stuff.If you go to the smoking cessation, all of the plan templates now havethis additional information in them. So if Im trying to hit PQRS and--wedid not make the rules here. There are two different code sets beingused for Meaningful Use for your quality reports and for Meaningful Usefor PQRS. They are different codes, and they are different code sets. Sothats the reason why we just put it all on a template for you. If youhave to click it twice, I apologize, but thats what it requires.The PQRS measure for cessation counseling requires 99406 or 99407.And I thought maybe that was a mistake, so I went and looked at theCode Master just to make sure, and those are the only two codes itsquerying for--no G-codes, which kind of surprised me. So those are thecodes that we put in this template for you. So its all right here for you.And once I do that, then that patient will hit my report. And thats all inthis new Content Update thats out there. Previously, it just had to bedone, it had to be done in a note, and those codes were there. Theywere all in this area right here. So theyve been there for a while. So ifyou were documenting them there, then you should still be getting credit.But it may depend on what codes are attached there. So right now, minehas a G-code in there, but I created that. That wasnt e-MDs content.So if Im going to do PQRS, I need 99406 and 99407. If Im going to be 15
  • 16. doing this clinical quality, then I can include the G-code. It queries for both, but PQRS only queries for 99406 and 99407.Fran Otte: Robin, just a reminder. Were about five minutes until the hour.Robin Bowles: Oh, wow.Fran Otte: I know. Its gone quickly. So if any of you are able to stay on any longer, we have allotted some extra time at the end, but we understand that some of you maybe need to go at one due to other obligations, so thank you.Robin Bowles: Yes, and I noticed that on the Chat, Lorraine said if you include your email address in the states name, she forwards that to me. If you have questions, Ill get each one of you answered, even if I cant address them all on the call. And if that requires that I need to pick up the phone and call you, Im happy to do that. Im here as a resource for you, and I will get you the answer that you need. Lets see. And then I had a question about, "How can you see the codes thats attached to an item in a flow sheet?" And what you have to do is-- so some of them may be already attached, but you dont know what code theyre attached to, and you want to know. And so Im going to go ahead and open up that Preventive Care Flow Sheet again. And lets see. For instance, on my DEXA. So no, it wasnt the DEXA, it was the flu shot. I was trying to create another flu shot field. So if I create the one for the Medicare--actually, no. Let me just go look at the DEXA so you can see how you can see that. So Im going to just edit that field. Im going to click on the Search for the data element, and then Im going to edit that data element. And right down here is where this Master Lab Code is, and so if you do that, and then you type in D for DEXA, it will show you the codes right here. So those are the actual CPT codes that are attached to the data element. And then you just back out of it, and it will leave it like it is. Okay? There was a question. Its been on here a couple of times, so I want to go ahead, and Im just going to reiterate your codes for smoking, and Im going to go ahead and just bring up the guide for the smoking measure. I think its done. Lets see. Thats mammograms. And there it is right there. Okay. So this outlines the codes. And if any of you are in desperate need of this, if you will get that information to Lorraine, she will get me a list of people that need this, Ill just send it directly to you. We wont wait on the Support Center. Ill just send it to you. 16
  • 17. So this is talking about Numerator A and Denominator A, because theres a numerator and a denominator, and there are two in this measure. So the first one is going to be all patients greater than or equal to age 18 at the beginning of the measurement period and that have two of the following visit cases. So its looking for any two of these. Or, and theres a lot of them like this. They go into this crazy detail about how many visits and what kind of visits. So this allows for one visit of any of these kind. So you really have to look at the code set. Now, the CPT codes that are in the chart note that identify patients smoking status are these. So only smokers are counted in this denominator, not all patients. I believe thats the way that works. Yes. Numerator B is going to be patients 18 or older that had cessation counseling within 24 months of the visit. So that indicates its got a two- year look-back from the visit note, and its looking for that 99406 or 99407. And this indicates that theyre looking for the G0436 and G0437. And then heres your Denominator B and your numerator information for that. Oh, I always do this, because I didnt do this one, so Im not as familiar with it as I am with some of the others. Oh, this is the one thats looking for a medication, so either an active medication, an existing medication in their current medications, or an order for a medication, which would be either a prescription or a refill. And its going to have to have a date on it, so its got to be done within a visit note. It can be done in current medications for a refill, but its got to be able to report it for the date, that that was done. Lets see. So Numerator B is looking for cessation counseling or that cessation was done via a medication. And then these are the codes its querying for in this specific report. Theres another report that only queries for 99406 and 407. So it just depends on which smoking report it is, because believe it or not, they were all different. And then we give you some workflow options for how to get that information into your chart notes so that it can be counted and queried by the report. Okay?Operator: There is a question on the line.Robin Bowles: Okeydoke.Operator: And as a reminder to everyone, if you do have a question that youd like to voice, please press the number seven on your telephone keypad. Questions will be taken in the order they are received. And if at any point your question has been answered, you may press seven again to disable your request. If you are using a speaker phone, we do ask that while posing your question, you could pick up your handset to provide favorable sound quality. The question on line is from Shirley Laidley of Ohio. Go ahead, Shirley. 17
  • 18. Shirley Laidley: Hello?Robin Bowles: Yes.Shirley Laidley: Oh, okay. Basically, I was wondering. You said that you would be sending out these measures to all of us?Robin Bowles: Yes, if youve given your email address, that will be forwarded to me, and then that way I can send you the documents. If theres specific documents that you need, but otherwise Im going to send you whatever youve requested in the email.Shirley Laidley: Okay, thank you.Robin Bowles: So I can get those to you sooner than theyll be reported on the Support Center, if I know who you are.Shirley Laidley: Thank you very much.Robin Bowles: Youre welcome. And then I had a question that said he was confused on whether the orange or green was for PQRS. So PQRS is green; Meaningful Use is burnt orange. So thats the difference between the two attributes. So if youre doing PQRS, youre going to click on the green. If youre doing National Quality Forum Measures for Clinical Quality Reporting, youre going to do the orange. I think thats it for questions.Operator: We have another question on the phone line.Robin Bowles: Okay.Operator: From Madonna Francois. Go ahead. Madonna, your line is unmuted. If your phone is muted on your end, please unmute it and state your question.Madonna Francois: Sorry about that. I was just asking for the code list.Robin Bowles: Thats in the Report Guide, so Ill send it to you.Madonna Francois: Yes, the documentation that you had on the screen a few minutes ago.Robin Bowles: Oh. Yes.Madonna Francois: Thats what I wanted. Thank you.Robin Bowles: You bet.Operator: Again, as a reminder, if you do have a question, please press the number seven on your telephone keypad. 18
  • 19. Robin Bowles: Lets see. So if its Numerator B that youre trying to hit, these are the code sets. These codes right here, which are your cessation codes for PQRS, and then these are all the medications that it queries for.Operator: Theres a question again from Madonna Francois. Go ahead.Robin Bowles: Okay.Madonna Francois: Sorry, for some--Robin Bowles: Yes. I see the question in the Chat. Ive got a question that says, oh, from practices that have already tried to update the templates to meet PQRS themselves, how will the template update affect them if they run it? Thats a really great question, and thank you for asking it. If you have edited a template, anything that you have created is automatically blocked from update. Okay, if you edited that item and created your own, it is not going to update that. So youre okay. Youre safe. And then there was a question that says, "Can you please explain why effective date has to be entered in for EHR direct reporting?" Effective date. Im not sure. Andrew, if you can just kind of tell me what you mean by effective date. Are you talking about the measurement period date? No, the effective date on the Medicare card. I dont know. I dont know why. I cant answer that question. That would be a question probably more for CMS. If its required, its for the file, then we were required to query for it. But why theyre requiring that, I dont know.Unidentified Participant: Hi, Robin. This is Kieran from MassPro. Im here with Lorraine. I have a question on the XML report that you generated. Would you go back to that?Robin Bowles: About the XML report? You want to show it one more time?Unidentified Participant: Yes, if you can go back to that, I have a question about that.Robin Bowles: You bet. This is last years, by the way, but yes, this is--.Unidentified Participant: This one here has two kinds of rates. It says performance rate and then a reporting rate. What are those two? Could you please explain that to me?Robin Bowles: Yes, I can. The reporting rate is, of the qualified population, how many of them are you reporting on? And were reporting on 100% of the patients that qualify. And then the performance rate is what was the actual threshold that you hit. 19
  • 20. Unidentified Participant: So if there are exclusions to the denominator, then the reporting rate would not be 100%? Is that right?Robin Bowles: No. Exclusions dont count against that. Exclusions are not included in the denominator at all or the report.Unidentified Participant: Is the reporting rate always going to be 100%?Robin Bowles: Yes, probably so. At least thats my knowledge of that. Now, this is not the current years file. Whether or not the one for this year will generate like this, and if thats something thats still in that QRDA file, I dont know yet. Hopefully, Im going to get a look at it next week, but Ive not seen it yet. "Does the PQRS denominator include Medicaid patients also?" No, I dont believe so. PQRS is specific to Medicare. So its only pulling Medicare populations.Lorraine Wanham: Hey, Robin, this is Lorraine. I just want to make sure that we get on the recording that if anybody needs any follow-up information, they can contact IHPC, which stands for Improving Health for Populations and Communities,, and someone would get back to you and get your information out to your state QIO for follow-up. Its in the Chat. Its been posted. But I just want to make sure we get it into the recording.Robin Bowles: Yes, thanks, Lorraine. I appreciate that. And youll forward that to me, right?Lorraine Wanham: Of course.Robin Bowles: Of course. Youve been so wonderful. Thank you. I did get a question that says, "Can we run the XML file to see where we are now?" That is a really large file, and I dont recommend running it. Yes, no, I dont recommend running it. Plus its not going to really be as representative as you would like it. The only reason I showed it was so you could kind of see how the report is formatted, because the QRDA formatting, I dont think, has changed completely. But it should be very similar. "One of my offices has Medicaid patients showing up on the detail." If theyre Medicare secondary, because it does include secondary and tertiary Medicare. "Robin, when generating the PQRS dashboard report, if a physicians name is not listed, how do you add the physician to the list?" Oh, my. That must mean that physician is not active in the software, so Im not really quite sure how they would not be showing up on that list. I think 20
  • 21. you need to create a support ticket for that. I cant diagnose that on thephone. If I could, I would.And actually, on the performance rate, like I said, I dont really know onthat particular one. That was actually CQM, that particular file, so itwasnt even looking at PQRS. So as far as e-MDs check performance,sure, 100% of applicable patients are included, the PQRS file may nothave that. I dont know. What I wanted to show you was that it willshow exclusions, it will show included patients. Mostly, I just wanted toshow you the format."If the effective date of Medicare insurance is missing, Corinne said thereport wont include the patient in the file transmitted." So thatsprobably good information for you guys to have. That effective date fortheir Medicare has got to be entered into the patients insurancedemographic if you want them on the report.Lets see. "And where do we find the S-codes and their explanations?Im not finding them in my HCPC (inaudible) notes." You probablywouldnt. You can check your HCPC reference, but we created them ascustom CPTs. And so if you look at the PQRS measure and the codesthat are being queried, thats how youre going to find them. Thats whythese documents are so important.And Im trying to get them on the Support Center as quickly as I can.Theyre ready to go. Were having some issues with the person that doesall that. So Ive got them all to him. Ive explained how important it is toget them out there. Weve given him screen shots of how we want it tolook, so Im hopeful that theyre going to be out there very, very soon. IfI can get them out there today, I may walk down there. I can just calland walk down there and say, "Hey, look. Please get them out theretoday, in whatever way that you can," so that you guys can start lookingat this.The CMS measures and the actual CMS measure specifications will alsobe out there, so were going to give you a link to those specificationsfrom the CMS website that you can download as well, so you have theirexplanation of the measure as well.But like all your PQRS stuff, and I dont know--I dont know how theyhave them linked in here. Like I said, if I know what the reporting codeis, then I can look it up here in my Search. But if you dont know what itis, then I get what youre saying. Its hard to look it up if you dont knowwhat it is. So you definitely do need to get that information, and itslisted in the PQRS Measure Specifications out on the CMS website. But itwill be listed in our documents as well. 21
  • 22. Access to the Support Center--talk to your Senior Rep at the QIO, because all of our QIOs have access to the Support Center, and they can give you the information on getting logged in.Operator: There is a question on the line.Robin Bowles: Okay.Operator: From Richard Blate of Georgia. Go ahead, Richard.Richard Blate: Hey, thanks for this. This is helpful, as always. A couple of questions. The effective date for the Medicare insurance policy--is that something new for PQRS at that level, or is it how you all are programming the reports to go? And the reason that I ask that is that the first time I heard it was a communication that Corinne had sent to all of us. And secondly, Ive seen a scenario where a practice has a chart, but they use something else for the practice management piece. The two products are kept separate with no connectivity between them. But the practice did set up insurances inside of the chart so that they could track it and things from that side.Robin Bowles: Right.Richard Blate: And then the NQF, and we ran the PQRS dashboard report, and it came up with nothing. And then we ran the NQF reports, and theres data all over the place.Robin Bowles: Yes, yes. And Ive got two explanations for that, and thats as much as I can give without looking at the specific scenario. But even though it looks like, when you look at, lets say, the Final Rule for Meaningful Use. The documentation puts the PQRS and the NQF report numbers side by side, like they were synonymous, and theyre not. They are different. The requirements are different, the code sets are different. And so what may show up on an NQF report for that very, very similar measure in PQRS, you may have different code sets. Now, if the code sets are exactly alike, which I found very few of them that were like that, because I did a comparison of every single one of them when I was working on the Clinical Product Team. So theyre different enough that the queries could not be identical. Otherwise, that would have been a piece of cake for us to develop, and we wouldnt have had to have gone through everything weve gone through. So thats kind of my answer for that. The other thing is, the 2011 dashboard, I believe, was updated for things like the flow sheet logic and stuff like that, but it doesnt contain, if the measure changed, it wont contain that. And so there may be changes to the query if there were any problems with the 2011 that we found out 22
  • 23. about later, that may be corrected in the 2012. So thats really as good as I can answer that question until I have a new dashboard to run.Richard Blate: Okay. And then my other question is more functional. Like going back to the HTN measure and the blood pressure, if someone in the practice just completely free-texted all of that information into the note and the note has been locked, can they go back in and edit the note to put in the historical data in there correctly?Robin Bowles: No.Richard Blate: Or how would that be done? Can it be done, and then how?Robin Bowles: I dont know of a way that can be done. They could try, using the Vitals Flow Sheet and entering that information directly into that flow sheet and using that date of that visit. They could try that. I dont know if it would work or not.Richard Blate: What about an addendum?Robin Bowles: Nope, thats text. Cant pick it up. Sorry. And then they need training. They need to get with somebody and get some training so that, you know, going forward they can do things so that their reports will capture it.Richard Blate: Thank you.Robin Bowles: Youre welcome. Sorry I couldnt provide more helpful advice.Lorraine Wanham: Okay, this is Lorraine. Were at, lets see, 2:20 if youre on the East Coast, 1:20 for Central. I think we can only take one more question, Robin, if you still have the time, and then were going to have to call it a day.Robin Bowles: You bet. One more.Lorraine Wanham: If anybody has a question.Operator: Again, as a reminder, if you do have a question, please press the number seven on your telephone keypad.Robin Bowles: Maybe we dont have any more questions.Lorraine Wanham: Okay, Im going to call it, then. Thank you, everybody. Once again, if you have any other questions and you want to use me as a point of contact at, Ill forward any information on to Robin or to your QIOs as it would deem appropriate, and hope we keep everybody 23
  • 24. informed. And our next session were planning should be some time in December. Dont have a date yet. Thank you, Robin, and we appreciate e-MDs providing this opportunity. Goodbye, all.Robin Bowles: Thank you. Bye-bye.Fran Otte: Thank you, and bye.Operator: Thank you. This does conclude todays teleconference. We thank you for your participation, and you may disconnect your line at this time. 24