Quality Measure Documentation Guide

Quality Measure Documentation Guide Table of Contents CMS 2- Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan (Ages 12 and older)... 3 CMS 22-Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented... 4 CMS 68- Documentation of Current Medications in the Medical Record (Ages 18 and older)... 4 CMS 69-Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up (18 and older)... 5 CMS 117-Childhood Immunization Status (2 years and under)... 6 CMS 122-Diabetes: Hemoglobin A1C Poor Control (Inverse measure) (Age 18-75)... 7 CMS 123-Diabetic Foot Exam... 7 CMS 124-Cervical Cancer Screening (Age 21-64)... 10 CMS 125-Breast Cancer Screening (age 50-74)... 10 CMS 127-Pneumonia Vaccination Status for Older Adults (65 and older)... 11 CMS 128-Anti-depressant Medication Management... 12 CMS 130- Colorectal Screening (Age 50-75)... 12 CMS 131-Diabetes: Eye Exam... 13 CMS 134-Diabetes: Medical Attention for Nephropathy... 14 CMS 136-ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication.. 15 CMS 138-Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (18 and older)... 16 CMS 139-Falls: Screening for Future Fall Risk... 17 CMS 146 Appropriate Testing of Children with Pharyngitis... 17 CMS 147-Preventive Care and Screening: Influenza Immunization (6 months and older)... 18 CMS 149-Dementia: Cognitive Assessment... 19 CMS 153 Chlamydia Screening for Women... 20 CMS 154- Appropriate Treatment for Children with Upper Respiratory Infection (URI) (Age 3 months to 18 years)... 20 1

CMS 155-Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (Ages 3-17)... 21 CMS 158-Pregnant Women That Had HBsAg Testing... 22 CMS 159-Depression Remission at Twelve Months... 23 CMS 161-Adult Major Depressive Disorder (MDD): Suicide Risk Assessment... 23 CMS 164 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet... 24 CMS 165-Controlling High Blood Pressure (Age 18-85)... 25 CMS 166-Use of Imaging Studies for Low Back Pain... 25 CMS 169-Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance abuse... 26 CMS 177-Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment... 27 Using the Visit Checklist... 27 Reviewing Health Maintenance Topics... 29 Documenting Refusal for Influenza Immunization... 30 Documenting External Results... 30 To enter External Results during an office visit:... 31 Scanning Results to an order using Media Manager... 32 Reviewing your Dashboard... 34 2

CMS 2- Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan (Ages 12 and older) Denominator Denominator Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen Patients screened for clinical depression on the date of the encounter using an age appropriate standardized tool and if positive, a follow-up plan is documented on the date of the positive screen. The follow-up plan must include one of the following: 1. Additional evaluation for depression 2. Suicide Risk Assessment 3. Referral to a practitioner who is qualified to diagnosis and treat depression. 4. Pharmacological Interventions 5. Other interventions or follow-up for the diagnosis or treatment of depression. All patients 12 years of age and older before the beginning of the measurement period with at least one eligible encounter during the measurement period Patients with an active diagnosis of depression or bipolar disorder Patient Reason(s) Patient refuses to participate OR Medical Reason(s) Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient's health status OR Situations where the patient's functional capacity or motivation to improve may impact the accuracy of results of standardized depression assessment tools. For example: certain court appointed cases or cases of delirium Organizational Goal: 64% Who must document this? Clinical staff or provider PHQ 2/9 is documented in the Rooming Tab. Refusal or medically unable to answer can be documented in the Visit Checklist. The follow up can be documented in the Visit Checklist. You can pull the most recent PHQ2/9 screening into your note by using the smartphrase.phq29. During the visit, you can find the last documented PHQ 2/9 by clicking on Last Filed in the upper right of the PHQ 2/9. If outside of the visit, you can see the last PHQ2/9 in Chart Review<Encounter<(find your office visit). At the bottom of the encounter you will see the PHQ 2/9 flowsheet hyperlink in blue. 3

CMS 22-Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated Patients who were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated if the blood pressure is pre-hypertensive or hypertensive All patients aged 18 years and older before the start of the measurement period with at least one eligible encounter during the measurement period Patient has an active diagnosis of hypertension Patient Reason(s) Patient refuses to participate (either BP measurement or follow-up) OR Medical Reason(s): Patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient's health status. This might include but is not limited to severely elevated BP when immediate medical treatment is indicated. Organizational Goal: 38% Who needs to document this? Clinical Staff Document BP at each visit. Print and give patient the AVS. 1.The AVS will include BP recommendations for the provider to get credit. 2.If patient has an active diagnosis of hypertension, add Hypertension to the Problem List with the onset date of the hypertension. CMS 68- Documentation of Current Medications in the Medical Record (Ages 18 and older) Percentage of visits for patients 18 and older for which the eligible professional attests to documenting, updating, or reviewing the patient's current medications using all immediate resources available on the date of the encounter. This list must include all known prescriptions, over-thecounters, herbals and vitamin/mineral/dietary (nutritional) supplements 4

AND must contain the medications' name, dosages, frequency, and route of administration. Eligible professional attests to documenting, updating, or reviewing the patient's current medications using all immediate resources available on the date of the encounter. This list must include all known prescriptions, over-the-counters, herbals and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosages, frequency, and route of administration. All visits occurring during the 12-month reporting period for patients 18 years and older before the start of the measurement period Denominator Denominator Patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient's health status Organizational Goal: 99% Who needs to document this? All Providers, care tech or nurse You must hit the Mark as Reviewed button in the Medication and Orders section on the day of EACH visit. If patient is not on any medications, select No Meds and select Mark as Reviewed. Reconcile Outside Medications CMS 69-Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up (18 and older) Percentage of patients aged 18 years and older with a BMI documented during the encounter or during the previous 6 months AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the encounter. Normal parameters: Age 18 or older: BMI >= 18.5 and < 25 Patients with a documented BMI during the encounter or during the previous six months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the encounter. 5

1. All patients who are 18 or older on the date of at least one eligible encounter during the measurement period Patients who are pregnant Patients who are receiving palliative care Patients who have refused measurement of height and/or weight or refuse follow up. Patients who have a medical or other reason documented explaining why BMI measurement wasn't taken (ie: urgent medical situation) Organizational Goal: 100% Who needs to document this? Provider Document Height and Weight at each visit. Must be documented in the note using the smartphrase.meaningfuluse and choose the BMI verbiage. You can also document the BMI follow-up in the Visit Checklist. Printing the AVS gives additional resources for weight management to the patient. If patient refuses to be weighed, refusal can be documented in the Visit Checklist. Adjust your templates to include the smartphrase.meaningfuluse. Your note must be signed for the Visit Checklist to recognize that the measure was documented against. CMS 117-Childhood Immunization Status (2 years and under) Percentage of children 2 years of age who had four diphtheria, tetanus, and acellular pertussis (DTaP); three polio (IPV); one measles, mumps, and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines before their 2nd birthday. Children who have evidence showing they received the recommended vaccines, had a documented history of the illness, had a seropositive test result, or had an allergic reaction to the vaccine before their 2nd birthday. Patients who turn two years of age during the measurement period and have a visit during the measurement period 6

Organizational Goal: 65% Who needs to document Pediatricians and Family Practice staff and providers this? This is all documented in the Immunization Activity as a historical or current immunization. If given in the hospital, this will flow to the Ambulatory documentation. Flu shots count for this measure. Check ICARE to update immunizations. Can reconcile ICARE from EPIC. Need 2 flu shots. Can check Health Maintenance or Rooming Tab HM to see what the patient is due for. CMS 122-Diabetes: Hemoglobin A1C Poor Control (Inverse measure) (Age 18-75) Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1C> 9.0% or no hemoglobin A1C test during the calendar year. Patients whose most recent HbA1c level (performed during the measurement period) is > 9.0% or who did not have an HbA1c test performed during the calendar year. Patients 18-75 years of age with a diagnosis of diabetes with a visit during the calendar year. Organizational Goal: 18% Who must document this? PCP This is a result based measure. If resulted externally, please follow the Documentation of External Results workflow and remember to scan result into the media tab using the scanning workflow. This is an inverse measure. You want the % on your dashboard to be lower than 18. The goal is to have <18% with an A1C > 9%. The patients In Numerator are those patients who haven t had an A1C done in the calendar year or the A1C they had in the calendar year is >9%. On your dashboard patient detail report, filter to look at patients who have MET (green check mark) the measure of A1C>9. Red x patients have an A1C<9%. CMS 123-Diabetic Foot Exam 7

Measure Description: Denominato r: Organization al Goal: Who needs to document this? Where to document this? The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection and sensory exam with mono filament and a pulse exam) during the measurement year Patients who received visual, pulse, and sensory foot examinations during the measurement period. Patients 18-75 years of age with a diagnosis of diabetes and a qualifying visit during the measurement period. Patients who had a bilateral foot/leg amputation during the measurement period. 69% Provider Use Dotphrase.footexam in provider s note or the foot exam in the Physical Exam in Notewriter. Can also document in Health Maintenance that the Foot Exam was done ONLY if the note includes a visual inspection, sensory exam with mono filament and a pulse exam. 8

Special Reminders: Need to address each section: sensory (with monofilament), vascular status (pulse), and skin integrity to meet the measure. 9

CMS 124-Cervical Cancer Screening (Age 21-64) Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following ways: 1. 21-64 years old- Cervical Cytology performed every 3 years 2. 30-64 years old- Cervical Cytology and HPV testing every 5 years. Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria: * Women age 21-64 who had cervical cytology performed every 3 years * Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years Women 23-64 years old with a visit during the measurement period Women who had a hysterectomy with no residual cervix; Hospice patients Organizational Goal: 81% Who must document this? Provider, nurse, medical assistant, MA Health Maintenance and Visit Checklist (if results are from an external source then use the workflow for documentation of External Results). The pap must be completed. It cannot just be ordered. If completed Externally, follow the Documenting External Results workflow. Document history of Hysterectomy in the Surgical History and this will exclude the patient from the measure. You can also document the exclusion in the Visit Checklist. Hysterectomy is the ONLY exclusion reason. Patient refusal does not count! If you are a specialty provider and patient does not have a PAP completed, please do the following: Educate the patient on the importance of getting Pap Identify if the patient has an OB/ GYN or a PCP who can perform PAP Identify the patient s PCP and send an inbasket message (if on Epic) or call the PCP to remind them the patient needs a PAP CMS 125-Breast Cancer Screening (age 50-74) Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer 10

Women 51-74 years of age on date of encounter Women who had a bilateral mastectomy or for whom there is evidence of two unilateral mastectomies. Organizational Goal: 80% Who must document this? Provider or office staff Documents external results in Rooming Tab or create a new Abstract encounter, if the patient is not there for a visit. If results are external, use the workflow for documenting External Results. Document the history of a bilateral mastectomy or 2 unilateral mastectomies in the Surgical History. Even though the measure is looking at patients 50-74, Riverside is using 40-74 yrs old. Patients will show on the HM at 40 yrs old but will show on the Visit Checklist at age 50 yrs old. The Mammogram needs to be completed. It cannot just be ordered. If completed Externally, follow the Documenting External Results workflow. The external result must be scanned into EPIC. You can link the HM Mammogram order to the scanned result. Put in the HM External Result via External Results order BEFORE you scan it in otherwise there will be no order to link the scanned document. CMS 127-Pneumonia Vaccination Status for Older Adults (65 and older) Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine Patients who have ever received a pneumococcal vaccine Patients 65 years of age and older with a visit during the measurement period Document vaccine in the Immunization Activity as a historical or current immunization. If given in the hospital this will flow to the Ambulatory documentation. Organizational Goal: 75% This counts if patient has one of the two pneumococcal vaccines. Health Maintenance looks at the series of 2 vaccines. 11

CMS 128-Anti-depressant Medication Management Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported: Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks) Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months) Numerator #1 - Patients who have received antidepressant medication for at least 84 days (12 weeks) of continuous treatment during the 114- day period following the Index Prescription Start Date. Numerator #2 - Patients who have received antidepressant medications for at least 180 days (6 months) of continuous treatment during the 231- day period following the Index Prescription Start Date Patients 18 years of age and older with a visit during the measurement period who were dispensed antidepressant medications in the time within 270 days (9 months) prior to the measurement period through the first 90 days (3 months) of the measurement period, and were diagnosed with major depression 60 days prior to, or 60 days after the dispensing event Patients who were actively on an antidepressant medication in the 105 days prior to the Index Prescription Start Date Organizational Goal: 93% Who needs to document this? Staff or provider Complete Med Rec when Rooming. Select Mark as Reviewed. CMS 130- Colorectal Screening (Age 50-75) Percentage of patients 50-75 years of age who had appropriate screening for colorectal cancer Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria: 12

Colonoscopy during the measurement period or the nine years prior to the measurement period (10 years) Cologuard every 3 years ifob/ FIT Test during the measurement period (1 year) Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period (5 years) CT Colonography Patients 50-75 years of age with a visit during the measurement period Patients with a diagnosis or past history of total colectomy or colorectal cancer. Document history of colectomy in the Surgical History. Organizational Goal: 72% Who must document this? PCP Documents external results in the Rooming Tab or create a new Abstract encounter. If results are external use the workflow for documenting External Results. Document the history of a total colectomy in the Surgical History. As we continue to use Epic and patients use Riverside for their care, topics will populate automatically. The ifob FIT)/ sigmoidoscopy/colonoscopy needs to actually be completed. It cannot just be ordered. If completed Externally, follow the Documenting External Results workflow. CMS 131-Diabetes: Eye Exam Percentage of patients 18-75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period Patients with an eye screening for diabetic retinal disease. This includes diabetics who had one of the following: A retinal or dilated eye exam by an eye care professional in the measurement period or a negative retinal exam (no evidence of retinopathy) by an eye care professional in the year prior to the measurement period All patients aged 18 years and older with a diagnosis of diabetic retinopathy. 13

Organizational Goal: 68% Who needs to document this? Rooming Staff can document in QM External Results after obtaining eye exam report Documents eye exam in external results in the Rooming Tab or create a new Abstract encounter. If results are external use the workflow for documenting External Results. The default frequency is one year. If the eye exam is negative for retinopathy, please change the frequency to two years. A copy of the eye exam needs to be on the chart because if it is negative, the patient can have it every 2 years. If positive, the eye exam must be done yearly. Communication - May include documentation in the medical record indicating that the findings of the dilated macular or fundus exam were communicated (eg, verbally, by letter) with the clinician managing the patient's diabetic care OR a copy of a letter in the medical record to the clinician managing the patient's diabetic care outlining the findings of the dilated macular or fundus exam. Findings - Includes level of severity of retinopathy (eg, mild nonproliferative, moderate nonproliferative, severe nonproliferative, very severe nonproliferative, proliferative) AND the presence or absence of macular edema. CMS 134-Diabetes: Medical Attention for Nephropathy Percentage of patients 18-75 years of age with diabetes who had a screening for nephropathy or evidence of nephropathy during the measurement period 14

Patients with a screening for nephropathy or evidence of nephropathy during the measurement period Patients 18-75 years of age with diabetes with a visit during the measurement period Organizational Goal: 93% Who needs to document this? Provider to order Urine Microalbumin every year Order Urine Microalbumin every year CMS 136-ADHD: Follow-Up Care for Children Prescribed Attention- Deficit/Hyperactivity Disorder (ADHD) Medication Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported: Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended Patient Population #1 - Patients who had at least one face-to-face visit with a practitioner with prescribing authority within 30 days after the IPSD. Patient Population #2 - Patients who had at least one face-to-face visit with a practitioner with prescribing authority during the Initiation Phase, and at least two follow-up visits during the Continuation and Maintenance Phase. One of the two visits during the Continuation and Maintenance Phase may be a telephone visit with a practitioner Patient Population #1 - Children 6-12 years of age who were dispensed an ADHD medication during the Intake Period and who had a visit during the measurement period Patient Population #2 - Children 6-12 years of age who were dispensed an ADHD medication during the Intake Period and who remained on the medication for at least 210 days out of the 300 days following the IPSD, and who had a visit during the measurement period 15

Exclusion #1 - Exclude patients diagnosed with narcolepsy at any point in their history or during the measurement period Exclude patients who had an acute inpatient stay with a principal diagnosis of mental health or substance abuse during the 30 days after the IPSD Exclude patients who were actively on an ADHD medication in the 120 days prior to the Index Prescription Start Date. Exclusion #2 - Exclude patients diagnosed with narcolepsy at any point in their history or during the measurement period Exclude patients who had an acute inpatient stay with a principal diagnosis of mental health or substance abuse during the 300 days after the IPSD Exclude patients who were actively on an ADHD medication in the 120 days prior to the Index Prescription Start Date Organizational Goal: 57% No specific documentation is required to meet this measure. It will be based on follow up visits within the 30 day Initiation Phase. CMS 138-Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (18 and older) Percentage of patients 18 years of age and older who were screened for tobacco (including smokeless) use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user Patients who were screened for tobacco use at least once within 24 months and who received tobacco cessation counseling intervention if identified as a tobacco user All patients 18 years of age and older who meet one of the following criteria with the EP during the measurement period: Have had at least two office visit, psychiatric, behavioral health, occupational therapy, or ophthalmological encounters Have had at least one preventative care, face-to-face interaction, or annual wellness encounter Patients with documentation of a medical reason or limited life expectancy for not being screened for tobacco use or for not receiving 16

tobacco cessation counseling if identified as a tobacco user who does not qualify for the numerator population Organizational Goal: 97% Who needs to document this? All providers This information is filled out in the Rooming Tab under the Vital Signs section. Counseling questions in the Tobacco Use section must be filled out on patients that are identified as smokers. Document smokeless tobacco use. Do not select unknown. CMS 139-Falls: Screening for Future Fall Risk Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period Patients who were screened for future fall risk at least once within the measurement period Patients aged 65 years and older with a visit during the measurement period Exclude patients who were in hospice care during the measurement year. Exclude patients who were assessed to be non-ambulatory during the measurement period. Patients with documentation of a medical reason for not screening for fall risk (e.g., patient is not ambulatory) Organizational Goal: 93% Who needs to document this? Provider or Clinical Staff Complete Falls Risk Screening in Rooming Section CMS 146 Appropriate Testing of Children with Pharyngitis Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic, and received a group A streptococcus (strep) test for the episode. A higher score indicates appropriate treatment of children with pharyngitis (e.g., the proportion for whom antibiotics were prescribed with an accompanying step test). 17

Children with a group A streptococcus test in the seven-day period from three days prior through three days after the diagnosis of pharyngitis Children 3-18 years of age who had an outpatient or emergency department (ED) visit with a diagnosis of pharyngitis during the measurement period and an antibiotic ordered on or three days after the visit Patients who are taking antibiotics for pharyngitis within 30 days before the encounter with a diagnosis of pharyngitis or are a Hospice patient during measurement period Organizational Goal: 93% Who needs to document this? Providers Clean up the Problem List. Remove old problems. Include proper diagnosis in Problem list. Order Group Strep A test. Order antibiotics. Use proper diagnoses: The following are included in the measure: Streptococcal pharyngitis (J02.0), Acute pharyngitis due to other specified organisms (J02.8), Acute pharyngitis, unspecified (J02.9), Acute streptococcal tonsillitis, unspecified (J03.0), Acute recurrent streptococcal tonsillitis(j03.01), Acute tonsillitis due to other specified organisms (J03.8), Acute recurrent tonsillitis due to other specified organisms (J03.81), Acute tonsillitis, unspecified (J03.90), Acute recurrent tonsillitis, unspecified (J03.91) CMS 147-Preventive Care and Screening: Influenza Immunization (6 months and older) Percentage of patients 6 months of age and older seen for a visit between October 1 and March 31 who received an influenza immunization or for those who have reported receiving an influenza immunization. Patients in the denominator who either received an influenza immunization or have documentation of previous receipt of an influenza immunization. January 2018- March 2018 is the 2016-2018 flu season. October 2018- December 2018 is the 2018-2018 flu season. All patients 6 months and older seen for at least 2 visits or at least one preventative visit during the measurement period (Flu Season). 18

Documentation of medical reason(s) for not receiving influenza immunization (e.g., patient allergy, other medical reasons) Documentation of patient reason(s) for not receiving influenza immunization (e.g., patient declined, other patient reasons) Documentation of system reason(s) for not receiving influenza immunization (e.g., vaccine not available, other system reasons) Patient has an active allergy to eggs Patient has an allergy to or intolerance of the influenza vaccine The documentation of reasons for not receiving influenza immunization and the allergy or intolerance are within 153 days before to 89 days after the start of the measurement period. Organizational Goal: 59% Who needs to document this? Clinical Staff and providers can document this. Document in the Immunization Activity as a historical or current immunization. Providers can document a patient s refusal in their note by using dotphrase.meaningfuluse and selecting the influenza immunization was not given. Also, refusal of the influenza immunization can be documented in the Visit Checklist. If given in the hospital this will flow to the Ambulatory documentation. CMS 149-Dementia: Cognitive Assessment Organizational Goal: 95% Who needs to document this? Provider Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period Patients for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period All patients, regardless of age, with a diagnosis of dementia Documentation of medical reason(s) for not assessing cognition (e.g., patient with very advanced stage dementia, receiving palliative care, other medical reason) Documentation of patient reason(s) for not assessing cognition 19

Complete the paper form (MOCA, Mini-Cog or Mini-Mental Exam). Scan the form into the Media tab. Use the dot phrase.meaningfuluse to satisfy this measure unless the assessment is done during a Medicare Wellness Visit (completed in the cognitive assessment portion of the note). The reminder for Cognitive Assessment will appear in the Visit Checklist. There is no link. Use the.meaningfuluse dot phrase in your note to satisfy the measure (unless you complete the cognitive exam during a Medicare Annual Wellness Visit) Needs to be completed every year. CMS 153 Chlamydia Screening for Women Organizational Goal: 62% Who must document this? Provider Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period Women with at least one chlamydia test during the measurement period Women 16-24 years of age who are sexually active and who had a visit in the measurement period Women who are only eligible for the initial population due to a pregnancy test and who had an X-ray or an order for a specified medication within 7 days of the pregnancy test Order must be entered Test needs to be resulted. Enter external results in QM External Results. CMS 154- Appropriate Treatment for Children with Upper Respiratory Infection (URI) (Age 3 months to 18 years) Percentage of children 3 months-18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode 20

Children without a prescription for antibiotic medication for pharyngitis on or three days after the outpatient or ED visit for upper respiratory infection Children 3 months to 18 years of age who had an outpatient or emergency department (ED) visit with a diagnosis of upper respiratory infection (URI) during the measurement period Children who are taking antibiotics in the 30 days prior to the date of the encounter during which the diagnosis was established or who had an encounter with a competing diagnosis within three days after the initial diagnosis of URI Organizational Goal: 95% Who needs to document this? All Providers treating children 3 to 18. This is an order based measure. DX codes that put the patient into the measure: (if these diagnoses are used- do not order antibiotic) J00 Acute nasopharyngitis [common cold] J06.0 Acute laryngopharyngitis J06.9 Acute upper respiratory infection, unspecified 460 Acute nasopharyngitis [common cold] 465.0 Acute laryngopharyngitis 465.8 Acute upper respiratory infections of other multiple sites 465.9 Acute upper respiratory infections of unspecified site CMS 155-Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (Ages 3-17) Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported: 1. Percentage of patients with height, weight, and body mass index (BMI) percentile documentation 2. Percentage of patients with counseling for nutrition 3. Percentage of patients with counseling for physical activity 21

1: Patients who had a height, weight, and BMI percentile recorded during the measurement period 2: Patients who had counseling for nutrition during the measurement year. 3: Patients who had counseling for physical activity during the measurement year. Patients 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or an obstetrician/gynecologist (OB/GYN) during the measurement period Patients with a diagnosis of pregnancy during the measurement period Organizational Goal: 80% Who must document this? Any provider who has an office visit with a child. Use.weightassessmentchild dot phrase. Must select both Exercise and Nutritional Counseling to meet the measure. CMS 158-Pregnant Women That Had HBsAg Testing This measure identifies pregnant women who had a HBsAg (hepatitis B) test during their pregnancy Patients who were tested for hepatitis B surface antigen (HBsAg) during pregnancy within 280 days prior to delivery All female patients aged 12 and older who had a live birth or delivery during the measurement period Patients with a diagnosis of hepatitis B that started or ended within 365 days prior to delivery Organizational Goal: 90% Who needs to document this? Provider Order Hep Bs Antigen or order as part of the OB Panel Measure will be met when the lab is resulted 22

CMS 159-Depression Remission at Twelve Months Organizational Goal: Who needs to document this? Patients age 18 and older with major depression or dysthymia and an initial Patient Health Questionnaire (PHQ-9) score greater than nine who demonstrate remission at 12 months (+/- 30 days after an index visit) defined as a PHQ-9 score less than five. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. Patients who achieved remission at twelve months as demonstrated by a twelve month (+/- 30 days grace period) PHQ-9 score of less than five Patients age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine during the index visit Patients who died Patients who received hospice or palliative care services Patients who were permanent nursing home residents Patients with a diagnosis of bipolar disorder Patients with a diagnosis of personality disorder There are no goals for this measure. Will measure percent over baseline. Rooming Staff PHQ2/9 in the Rooming Section CMS 161-Adult Major Depressive Disorder (MDD): Suicide Risk Assessment Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified Patients with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified All patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) 23

Organizational Goal: 96% Who needs to document this? Rooming Staff Suicide Assessment in the Rooming Section CMS 164 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period Patients who had an active medication of aspirin or another antiplatelet during the measurement year. Oral antiplatelet therapy consists of: aspirin, clopidogrel, combination of aspirin and extended release dipyridamole, prasugrel, ticagrelor or ticlopidine. Patients aged 18 years of age and older with a visit during the measurement period who had an AMI, CABG, or PCI during the 12 months prior to the measurement year or who had a diagnosis of IVD overlapping the measurement year Denominator exclusion- Hospice services for patient received any time during the measurement period or Patients who had documentation of use of anticoagulant medications( Apixaban, Argatroban, Bivalirudin, Dabigatran, Dalteparin, Desirudin, Edoxaban, Enoxaparin, Fondaparinux, Heparin, Lepirudin, Rivaroxaban, Tinzaparin, or Warfarin) overlapping the measurement year Anticoagulant medications consist of: Organizational Goal: 84% Who must document this? Provider Clean up Problem List. Ensure patient is on antiplatelet medication. Need to be on antiplatelet (not anticoagulant- unless anticoagulant overlaps during the measurement year) 24

CMS 165-Controlling High Blood Pressure (Age 18-85) Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mmhg) during the most recent qualifying visit during the measurement period. Patients whose blood pressure during the patient's most recent visit is adequately controlled (systolic blood pressure < 140 mmhg and diastolic blood pressure < 90 mmhg). Patients 18-85 years of age who had an active diagnosis of essential hypertension within the first six months of the measurement period. Patients with an active diagnosis of end-stage renal disease (ESRD) or stage 5 chronic kidney disease during the measurement period Patients who had a dialysis, renal transplant, ESRD monthly outpatient services, or vascular access for dialysis procedure before or during the measurement period. Patients with an active diagnosis of pregnancy during the measurement period. Organizational Goal: 75% Who needs to document this? All providers Rooming Tab in the Vital Signs section This looks at the most recent blood pressure taken for all patients that have hypertension listed on their problem list or as a visit diagnosis. If the patient s pressure is close to being less than 140/90, re-take the BP because the patient may just have white coat syndrome. The last BP taken during the visit will be the BP used to satisfy the measure. Do not use patient s home BP Log Take BP on all patients CMS 166-Use of Imaging Studies for Low Back Pain Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis 25

Patients without an imaging study conducted on the date of the outpatient or emergency department visit or in the 28 days following the outpatient or emergency department visit Patients 18-50 years of age with a diagnosis of low back pain during an outpatient or emergency department visit Patients with a diagnosis of cancer any time in their history or patients with a diagnosis of recent trauma, IV drug abuse, or neurologic impairment during the 12-month period prior to through the 28 days after the outpatient or emergency department visit Patients with a diagnosis of low back pain within the 180 days prior to the outpatient or emergency department visit Organizational Goal: 82% Who needs to document this? No special documentation. Do not order an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis of back pain as an Outpatient or during an ED visit. Document exclusions in the medical history. CMS 169-Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance abuse Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use Patients in the denominator with evidence of an assessment for alcohol or other substance use following or concurrent with the new diagnosis, and prior to or concurrent with the initiation of treatment for that diagnosis Patients 18 years of age or older at the start of the measurement period with a new diagnosis of unipolar depression or bipolar disorder during the first 323 days of the measurement period, and evidence of treatment for unipolar depression or bipolar disorder within 42 days of diagnosis. The existence of a 'new diagnosis' is established by the absence of diagnoses and treatments of unipolar depression or bipolar disorder during the 180 days prior to the diagnosis. 26

Organizational Goal: Who needs to document this? Provider Complete AUDIT-C in the Clinical Assessment activity. Patient has not had an assessment for alcohol or substance abuse will appear in the Visit Checklist if it needs to be completed. Click on the link in the Visit Checklist to complete the AUDIT-C Assessment. CMS 177-Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk Patient visits with an assessment for suicide risk All patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder Organizational Goal: 80% Who needs to document this? Provider Complete the Columbia Suicide Assessment (C-SSRS)- Lifetime/Recent or Since Last Visit in the Clinical Assessment activity. This patient has a diagnosis of Depression and has not had a suicide risk assessment will appear in the Visit Checklist if it needs to be completed. Click on the link in the Visit Checklist to complete the Columbia Suicide Risk Assessment. Using the Visit Checklist 1. Before you close the visit, click on the Visit Checklist tab found in the Sidebar. On this tab you can check if you have properly documented the required measures. Objectives that are not met under the Visit Checklist will appear with a yellow yield sign next to them. 2. Click Check Quality Measures to see if you are missing any required documentation. 27

3. A checklist will generate for you review of the measures. If you are missing items, clicking Add button next to the appropriate choice will apply the information or document this in the section of the chart in which it lives. Click the Apply Selected box (number 1) to update the documentation. See Last Refreshed (number 2). 5.) To view what Quality measures are satisfied click on Currently Satisfied (number 3) 28

Reviewing Health Maintenance Topics Health Maintenance was designed to be used as a preventative health tool to communicate with patients. Health maintenance reminders are sent to patients through MyChart. Health Maintenance displays for providers and clinical staff to serve as a visual reminder of the different preventative screenings that patients may need. Think of the Health Maintenance section as a View only or a To do tab. To review the Health Maintenance Topics for a patient, use the following steps. 1. When the Health Maintenance Tab is highlighted yellow the patient is due or is outstanding preventative health measures. From the Patient s Chart, click on the Health Maintenance tab in the Header. 2. In the table, review pending or overdue Health Maintenance procedures for your patient. In the first column, view the status of each pending or overdue Health Maintenance procedure. Use the legend that appears under the table to determine whether the procedure is overdue, due, or due soon. In the Due Date column, view the date each Health Maintenance procedure is due. In the Date Completed column, view the date each Health Maintenance procedure was addressed. If there is an override, the override type is listed in parentheses. 29

3. The patient s Health Maintenance plans are listed below the topics section. 4. Providers can react to alerts by using the Visit checklist in the sidebar. For further information about documenting on each individual measure, please see specific measure in guide above. Documenting Refusal for Influenza Immunization Use the Postpone button to document that a patient refused, was unable to get due to insurance, doesn t have time, is ill, or if there is a drug shortage. Please postpone the immunization until the next flu season if the patient refuses. Documenting External Results To document external mammography, colonoscopies, PAP smears, and Hemoglobin A1c not completed at Riverside Healthcare. This can be documented by clinical staff in QM External Results. Once this information is entered in QM External Results it will satisfy Health Maintenance. Remember, you must have the actual result to document in QM external results. You can enter external results during a visit or when a patient is not in the office. 30

To enter External Results during an office visit: 1. Go to the Rooming tab and find the section label QM Ext Results. 2. Open this section and click on the icon document on the individual result. To enter external results on more than one section click the icon next to the Health Maintenance section. DO NOT Click order. 3. Document see scanned result in the comment field and the date of the test (not the scanned date) in the date field. Enter the time of 2359 in the time field. What you write in the comments section will populate in the proper tab. Pap smears and Hemoglobin A1c will result on the labs tab. Mammograms are found under imaging and colonoscopies will be found under the procedure tab. 4. Finally, go to the Health Maintenance section by clicking Health Maintenance section in the header. 5. Update the dates and the Health Maintenance topics by clicking the Update HM button. 6. Please scan the results to the order by using Media Manager. Documenting results outside of an office visit These steps are to be followed if result was faxed to the office. 1. From the Epic button, go to Patient care and select Encounter. 2. Search for the patient. 31

3. Then select New encounter. 4. Enter in a New encounter type of Abstract. Do NOT select Manual Abstraction. Provider can be defaulted to their PCP. Click on PCP. Click accept. 5. From the abstract encounter navigator, you will follow steps 1-5 of Documenting Results through an Office Visit 6. Click Sign Visit to complete the Abstract encounter. Scanning Results to an order using Media Manager You can complete scanning workflows from within Epic using Media Manager. Use Media Manager to view and acquire scans at the order level. You will scan to the HM order 1. Go to Epic Button > Patient Care > Media Manager. 2. Look up the patient whose scan you're adding. 3. Select the drop-down menu and select Choose an Order. a. Order Level This scan is a result that will be attached to an individual order. i. The order must have been entered in Epic to be able to scan to it. 32

4. The Order Selection window appears. Find and select the order you want to scan to. You can adjust the date range as necessary. It is best to choose the Search option of all. Verify you are selecting an order that has an Authorizing Provider of Historical Provider. See the screen shot of the health maintenance orders below. The orders have prefix of HM. 5. Click Scan on the activity toolbar. The Scan window opens. 6. Chose the Scan button. 7. After the document is scanned, you will see it appear on the right side of the scan activity. Verify the scanned image is viewable. 8. Select the icon to the right of the Scan button you previously selected. 9. In the Document Description field, enter a specific description of the document you scanned in. 33

10. Click OK. 11. Click Upload Images to save the scans to the patient record. 12. Close out of the scan activity. Reviewing your Dashboard To improve upon your own results and Riverside s results, please review your dashboard. The dashboard gives you the ability to drill down to see patients that have fallen out of the measure. Review the steps below to review your results. Reports are run weekly on Mondays. 1. Click your dashboard tab. The RMC OP Clinical Metric Trends: Physician dashboard houses all the Quality Measures. 34

2. If it is not set as the default, Click the square and find the RMC OP Clinical Metric Trends: Physician 3. The Quality Measures Dashboard is color coded using red, yellow, and green. Hoovering over each percentage will show the goal and thresholds. 4. To drill down to the specific measure, left click on the score and select View Patients. 35

5. You can sort the patients by using the Filters. For the A1C measure, look at those patients with a green checkmark (because they MET the measure of the definition that is A1C > 9). For all other measures besides A1C, look at those patients with the red X. 36