1. 2013 Prevalidated PCMH 2011 Factors
NCQA PCMH 2011 Standard Elements and Factors Phytel Product Application
Prevalidated by NCQA
PCMH 1: 1D 2, 1G 2 and 6 Insight, Coordinate, Population
Enhance Access and Continuity Health Services
PCMH 2: 2D 1-3* Outreach
Identify and Manage Populations
PCMH 3: 3A 1-3, 3B 1, 3C 1, 6 & 7* Insight, Coordinate, Outreach
Plan and Manage Care
PCMH 4: 4A 1*, 4B 4 Coordinate
Provide Self-Care Support and
Access to Community Resources
PCMH 5: 5C 4 Transition
Track and Coordinate Care
PCMH 6: 6A 1 & 2, 6A 4, Insight, Coordinate
Measure and Improve Performance 6C 1 & 3*, 6D 1, 6E 1-3
Autocredit
*Must Pass

2. PCMH 2011 Prevalidation Step-by-Step Guide
Client Practices & Participating Vendors
Outline of Steps Practices that want to use autocredit for Vendors that want to submit products for
for Participation the PCMH 2011 Survey: NCQA PCMH 2011 prevalidation:
Step 1: Obtain the NCQA-issued Step 1: Purchase the PCMH 2011 Survey
Prevalidation Summary Approval Tool and attend NCQA’s Free ISS
Table and NCQA Letter of Product Trainings and/or an onsite Facilitating
Autocredit Approval from the PCMH training session.
vendor, in addition to a letter of
vendor products implemented and
the date of implementation. Step 2: Identify factors whose functionality
requirement is met by the product,
using Documentation Guidelines
Step 2: Implement prevalidated products Data Sources as a guide.*
for a minimum of 3 months before
submitting the Survey Tool.
Step 3: Request a program Agreement at
PCMH@ncqa.org.
Step 3: Complete an application and enter
into required agreements for the
NCQA Recognition program. Step 4: Submit the executed PCMH 2011
Prevalidation Program Agreement,
Program Application and Application
Step 4: Upload the vendor Prevalidation Checklist; submit the application fee
Summary Approval Table, per the Program Fee Schedule.
implementation letter and a copy of
the NCQA Letter of Product
Autocredit Approval into the Survey Step 5: Pre-submission demo call with
Tool’s document library. NCQA.
Step 5: Upload specified documentation Step 6: Complete the PCMH Survey Tool;
into the document library, and for alert NCQA of the intended
each factor awarded autocredit, submission date; send the final
enter the Attestation Statement into payment.
the factor’s “notes” field.
Step 7: NCQA reviews the survey and
Step 6: Submit the Survey Tool. reports the scoring decision in
45–60 days.
Note: Find attestation language in the Letter
of Product Autocredit Approval provided by Step 8: Receive:
the vendor.  Prevalidation Summary Approval
Table.
 Letter of Product Autocredit
Approval.
 Marketing & Advertising
Guidelines.
Step 9: Send proposed press release
language and other marketing
materials to NCQA for approval.
* If a product’s functionality does not fully meet
the factor’s requirement, NCQA will list all
factors submitted, but not approved for
autocredit on the Prevalidation Summary
Approval Table.
1-28-2013

3. NCQA’s PCMH 2011 Pre-Validation Summary Approval Table
Phytel Outreach v.6.1.3; Phytel Insight v.1.4;
Phytel Coordinate v.0.9.2
Points Factors Factors Factors
Standard and Element Reported Not
Approved Scored
Not Scored Reported
1 Enhance Access and Continuity
A Access During Office Hours (Must Pass) 1-4
B After-Hours Access 1-5
C Electronic Access 1-6
0.50 D Continuity (Insight) 2 1,3
E Medical Home Responsibilities 1-4
F Culturally and Linguistically Appropriate Services (CLAS) 1-4
G The Practice Team (Coordinate; Insight & Pop Health Svcs) 2,6 1, 3-5,7,8
2 Identify and Manage Patient Populations
A Patient Information 1-12
B Clinical Data 1-9
C Comprehensive Health Assessment 1-9
3.75 D Use Data for Population Management (Must Pass) (Outreach) 1-3 4
3 Plan and Manage Care
4.00 A Implement Evidence-Based Guidelines (Insight; Coordinate) 1-3
B Identify High-Risk Patients (Insight) 1 2
C Care Management (Must Pass) (Coordinate; Outreach) 1,6-7 2-5
D Medication Management 1-6
E Use Electronic Prescribing 1-6
4 Provide Self-Care Support and Community Resources
1.50 A Support Self-Care Process (Must Pass) (Coordinate) 1 2-6
B Provide Referrals to Community Resources (Coordinate) 4 1-3
5 Track and Coordinate Care
A Test Tracking and Follow-Up 1-10
B Referral Tracking and Follow-Up (Must Pass) 1-7
C Coordinate with Facilities/Care Transitions (Transition) 4 1-3,5-8
6 Measure and Improve Performance
3.00 A Measure Performance (Insight) 1-2 4 3
B Measure Patient/Family Experience 1-4
C Implement Continuous Quality Improvement (Insight;
1,3 2,4
Coordinate)
D Demonstrate Continuous Quality Improvement (Insight) 1 2-4
E Report Performance (Insight) 1-3
F Report Data Externally 1-4
G Use Certified EHR Technology 1-2
12.75 Points 10 Factors 15 Factors
Practice/Group Name: Implementation Date:
Approved Conditions (if applicable): Hypertension, Diabetes, Hypercholesterolemia, CAD, Obesity
Product Validation Date: 4/30/12

4. PCMH 2011 Prevalidation Program
Letter for of Product Autocredit Approval
4/30/2012
Karen Handmaker
VP, Population Health Strategies
Phytel, Inc.
11511 Luna Rd
Dallas, TX 75234
Phytel Outreach v.6.1.3; Phytel Insight v.1.4; Phytel Coordinate v.0.9.2
Dear Ms. Handmaker:
NCQA would like to congratulate Phytel, Inc. on developing the Phytel Outreach, Insight
and Coordinate solutions which have been awarded a total of 12.75 points in PCMH
2011 Autocredit. As of 4/30/2012, Phytel Inc. client practices utilizing Phytel Outreach,
Coordinate and Insight may benefit from reduced documentation and have scoring
associated with awarded Autocredit applied to their total PCMH 2011 Survey score. This
is contingent upon the eligible practice or practice group and athenahealth, inc. meeting
the requirements outlined in the attached PCMH 2011 Prevalidation Step-by-Step Guide
for Client Practices and Participating Vendors.
The documents accompanying this letter include: NCQA’s PCMH 2011 Prevalidation
Summary Approval Table; Program Marketing & Advertising Guidelines; PCMH 2011
Prevalidation Program Step-by-Step Guide. It is essential that you read all
documents thoroughly.
Phytel Inc. will be listed on NCQA’s PCMH Prevalidation Program webpage. Visitors to
the site will be directed to pcmh@phytel.com to receive additional product related
information.
Below is a summary of the Autocredit awarded by product name(s) and the associated
attestation language required for eligible practices to enter into their PCMH ISS Tool in
order for awarded Autocredit to be applied to the total score of the practice’s PCMH
2011 Survey.
Total Autocredit Factors Approved for
Product Name Attestation Statement
Awarded Autocredit
Practice attests to the implementation
Phytel and use of Phytel Outreach v.6.1.3 for
Outreach 3.75 Points PCMH2:D:1-3 associated Autocredit points as specified
v.6.1.3 in the attached NCQA Prevalidation
Summary Approval Table.
1|P age

5. Total Autocredit Factors Approved
Product Name Attestation Statement
Awarded for Autocredit
Practice attests to the implementation and
PCMH1:D:2
Phytel Insight use of Phytel Insight v.1.4 for associated
7.5 Points PCMH3:A:1-3
v.1.4 autocredit points as specified in the attached
PCMH6:A:1-2
NCQA Prevalidation Summary Approval Table.
Total Autocredit Factors Approved
Product Name Attestation Statement
Awarded for Autocredit
Practice attests to the implementation and
Phytel PCMH3:A:1-3
use of Phytel Coordinate v.0.9.2for associated
Coordinate 5.5 Points PCMH4:A:1
autocredit points as specified in the attached
v.0.9.2
NCQA Prevalidation Summary Approval Table.
Sincerely,
Mina Harkins
Mina L. Harkins, BSMT(ASCP), MBA
NCQA AVP, Recognition Programs
2|P age

6. How Phytel Supports Compliance with NCQA PCMH 2011 and ACO Standards
March 2013
The Phytel platform is designed to help build a high performance Patient-Centered Medical Home based on
population health management principles and best practices. A number of functions directly support specific
elements of the PCMH 2011 standards set forth by NCQA and have been pre-validated for autocredit in the NCQA
application process. Many other Phytel-enabled functions, when executed by the care team in the process of care
delivery, enable demonstrated compliance with additional elements required to meet standards related to the
management and coordination of care, fostering self-management capabilities, and demonstrating ongoing quality
improvement.
Phytel’s implementation process prepares clients planning to apply for NCQA PCMH recognition by recommending
relevant Outreach protocols and Insight measures, focusing on provider attribution and data integrity, and
providing sample care management and quality improvement workflows that tie to specific standards and
elements.
The following table lists specific NCQA PCMH standards and elements that are supported by functions within the
Phytel platform. Factors in red are approved for autocredit; factors in blue are approved as support for the
practice’s documented processes and activities for the related elements. In addition, where related NCQA’s ACO
2012 to PCMH 2011 Crosswalk has indicated commonality between the standards, this is noted.
Standard 1: Enhance Access and Continuity
1D: Continuity The practice provides continuity of care for patients/families by:
(multi-site)  Factor 2: Documenting the patient’s/family’s choice of clinician
(ACO PC 1 K)
1G: The Practice Team The practice provides a range of patient care services by:
(multi-site)  Factor 2: Having regular team meetings or a structured communication process (“critical factor”)
 Factor 6: Training and assigning care teams for patient population management
(ACO PC 1 C)
Standard 2: Identify and Manage Populations
2D: Use Data for Population The practice uses patient information, clinical data and evidence-based guidelines to generate lists of
Management patients and to proactively remind patients/families and clinicians of services needed for:
MUST PASS  Factor 1: At least three different preventive care services
(multi-site)  Factor 2: At least three different chronic or acute care services
 Factor 3: Patients not recently seen by the practice
Standard 3: Plan and Manage Care
3A: Implement Evidence- The practice implements evidence-based guidelines through point of care reminders for patients with:
Based Guidelines  Factor 1: The first important condition
 Factor 2: The second important condition
(ACO PO 2 A and PC 1 D)  Factor 3: The third condition, related to unhealthy behaviors or mental health or substance abuse
11511 Luna Road, Suite 600 | Dallas, TX 75234 | 800.559.3057 | f 972.991.9296 | phytel.com ©2013 Phytel, Inc. All rights reserved.

7. 3B: Identify High- Risk To identify high-risk or complex patients the practice:
Patients  Factor 1: Establishes criteria and a systematic process to identify high-risk or complex patients
(ACO PC 1 D)
3C: Care Management The care team performs the following for at least 75 percent of the patients identified in Elements A
MUST PASS and B:
 Factor 1: Conducts pre-visit preparations
(ACO PC 1 E)  Factor 6: Identifies patients/families who might benefit from additional care management support
 Factor 7: Follows up with patients/families who have not kept important appointments
Standard 4: Provide Self-Care Support and Access to Community Resources
4A: Support Self-Care Process The practice conducts activities to support patients/families in self-management:
MUST PASS  Factor 1: Provides educational resources or refers at least 50 percent of patients/families to
educational resources to assist in self-management
(ACO PC 1 G and CM 4 C)
4B: Provide Referrals to The practice supports patients/families that need access to community resources:
Community Resources  Factor 4: Offers opportunities for health education programs (such as group classes and peer
support.)
(ACO PC 1 G and CM 4 C)
Standard 5: Track and Coordinate Care
5C: Coordinate With Facilities On its own or in conjunction with an external organization, the practice systematically:
and Care Transitions  Factor 4: Demonstrates its process for contacting patients/families for appropriate follow-up care
within an appropriate period following a hospital admission or emergency department visit
Standard 6: Measure and Improve Performance
6A: Measure Performance The practice measures or receives data on the following:
 Factor 1: At least three preventive care measures
 Factor 2: At least three chronic or acute care clinical measures
 Factor 4: Performance data stratified for vulnerable populations (to assess disparities in care).
6C: Implement Continuous The practice uses an ongoing quality improvement process to:
Quality Improvement  Factor 1: Set goals and act to improve on at least three measures from Element A
MUST PASS  Factor 3: Set goals and address at least one identified disparity in care/ service for vulnerable
populations
(ACO PC 1 J)
6D: Demonstrate Continuous The practice demonstrates ongoing monitoring of the effectiveness of its improvement process by:
Quality Improvement  Factor 1: Tracking results over time
6E: Report Performance The practice shares performance data from Element A and Element B:
 Factor 1: Within the practice, results by individual clinician
 Factor 2: Within the practice, results across the practice
 Factor 3: Outside the practice to patients or publicly, results across the practice or by clinician.
11511 Luna Road, Suite 600 | Dallas, TX 75234 | 800.559.3057 | f 972.991.9296 | phytel.com ©2013 Phytel, Inc. All rights reserved.