Computerized Provider Order Entry (CPOE) for Medication Orders

Computerized Provider Order Entry (CPOE) for Medication Orders:

>30% of all unique patients with at least one medication in their medication list seen by the EP during the EHR reporting period have at least one medication order entered using CPOE.

• This will likely be taken care of by your normal practices, just taking care of patients and having the EP enter their medication orders in EHR
• The logic is looking for medication with an Issue Date during the reporting period
• It also looks for the Nature of Order. It does not count if Nature of Order = Written.
• It counts for holders of the ORES key. It will count for holders of the ORELSE key if they correctly enter the order under the EP’s name. Policy orders are a bit of a gray area – stay tuned for clarification in MU Stage 2.
• The EP is excluded if they write less than 100 prescriptions in the reporting period
• If you do not have an onsite RPMS pharmacy, you can still meet this one (but that doesn’t much matter because you can’t meet the e-Prescribing one – and both measures are required)

Drug Interaction Checks:

The EP has enabled this functionality for the entire EHR reporting period.

• You just answer Yes or No for this
• This is all about getting your Clean Date set.
• The Clean Date must be set prior to the start of your reporting period
• It is a one-time thing – once your Clean Date is set, you do not have to do it again
• Instructions on setting your Clean Date are on pages 20-35 of this document
• One way to check if your clean date is set is to do ^MUCD. If a date is shown, you’re set.

• This will likely be taken care of by routine clinical practice.
• Note it does not say you have to document that you reviewed the problem list at each visit (that may be good clinical practice, but it is not required to meet this measure
• If there is an active problem on a patient’s problem list that is not updated in any way during the reporting period, that meets the objective
• If a problem is added or deleted or otherwise updated during the reporting period, that meets the objective
• If the patient truly has no active problems, this is when you use the review button (or right click on the Problem List component) and select “No Active Problems” to get credit for maintaining that patient’s problem list

Active Medication List:

>80% of all unique patients seen by the EP during the EHR reporting period have at least one entry (or an indication that the patient has no active medications) recorded as structured data.

• This will likely be taken care of by routine clinical practice.
• Note it does not say you have to document that you reviewed the medication list at each visit (that may be good clinical practice, but it is not required to meet this measure)
• The logic is only looking at a combination of the issue date and the discontinue date (if there is one). Here are some scenarios:
• If there is an active medication on the patient’s list that is not refilled during the reporting period - that is fine, it still counts
• If a medication was active, but expires during the reporting period – that is fine, it still counts
• If a medication is active during the reporting period, but is discontinued before the end of the reporting period – that is fine, it still counts
• If a new medication is ordered during the reporting period, it counts - regardless of where, or if it is filled
• If there is a medication in the Outside Medications component documented as active, it counts
• If the patient truly has no active medications, this is when you use the review button (or right click on the Medication List component) and select “No Active Medications” to get credit for maintaining that patient’s medication list

Medication Allergy List:

>80% of all unique patients seen by the EP during the EHR reporting period have at least one entry (or an indication that the patient has no known medication allergies) recorded as structured data.

• This will likely be taken care of by routine clinical practice.
• Note it does not say you have to document that you reviewed the allergy list at each visit (that may be good clinical practice, but it is not required to meet this measure)
• If there is an active allergy listed in the patient’s list in the Adverse Reaction Tracking package and is not updated in any way during the reporting period – that is fine, it counts
• If the patient has no known allergies, and that is already documented in the ART package – that is fine, it counts
• If the patient has no known allergies, and that is not already documented in the ART package, this is when you Right click on the Allergies/Adverse Reactions List component) and choose “New Adverse Reaction” and thenclick the “No Known Allergies” box at the bottom of the dialog that appears to get credit for that patient for this measure.
• The allergy chart review button does not play a direct role in meeting this measure - though as stated before, can be part of good clinical practice
• Note: an allergy listed on the patient’s Problem List alone will not count for this measure – the reaction must be documented in the Adverse Reaction Tracking package. Periodically running the PLAL list to identify allergies on problem lists is part of a good maintenance routine for your ART Package.

e-Prescribing (eRx):

>40%of all permissible prescriptions written by the EP during the EHR reporting period are transmitted electronically using certified EHR technology.

• An EP is excluded if they write < 100 prescriptions during the reporting period
• For RPMS EHR, if you write medications in EHR and they are filled at an on-site RPMS Pharmacy, you can meet this measure
• Controlled Substances and medications marked as “Administered in Clinic” are excluded
• If you do not use an RPMS Pharmacy, you will need the RPMS e-Prescribing package (BPER)
• This allows you to send prescriptions directly from RPMS EHR to an outside pharmacy or an onsite COTS pharmacy
• This was officially released in March 2012 as a controlled roll out
• There are many prerequisites to going live on e-Prescribing
• To get more information, contact Katie or Neill

Record Demographics:

>50% of all unique patients seen by the EP during the EHR reporting period have all demographics recorded as structured data.

• There are 5 items the logic is looking for: Preferred language, Race, Ethnicity, Sex, and Date of Birth. It is simply looking for the presence of something in each of these fields in Patient Registration package during the reporting period
• Mark these as mandatory in the Patient Registration Package
• Any one of these items that is missing will count against you in this measure

Record Vital Signs:

>50% of all unique patients age two years or older seen by the EP during the EHR reporting period have height, weight, and blood pressure recorded as structured data.

• Use EHR Vitals entry to enter height, weight, and blood pressure
• The logic looks for the presence of data in these 3 fields during the reporting period
• It is not required that you enter these vitals at every visit, though it may be good clinical practice
• It does not matter who enters the vitals – may be MA or nurse or doc or pharmacist, etc

Record Smoking Status:

>50% of all unique patients 13+ years or older seen by the EP during the EHR reporting period have smoking status recorded as structured data.

• Use the Tobacco (Smoking) health factor to document smoking status in EHR
• The logic is looking specifically for the presence of one of these health factors in the reporting period
• Current smoker, every day
• Current smoker, some day
• Current smoker, status unknown
• Previous (former) smoker
• Never smoked
• Smoking status unknown
• It is not necessary to document it at every visit
• Reminders and Reminder Dialogs can be very handing both in helping you to know when to screen patients and in documenting the health factor

Clinical Quality Measures (CQM):

Successfully report Clinical Quality Measures to CMS or appropriate state Medicaid.

• There are no targets to meet for these measures, but you do have to report on them
• In order to do that, you need to run the EP Clinical Quality Measure Report from CRS for your reporting period
• Save the report, you will have to enter these numbers in either your state’s attestation website (if Medicaid) or CMS’s website (if Medicare) at the time of attestation
• When running the report, choose the Selected Measures (UserDefined) report
• Choose three core or alternate core measures (marked with (C) and (A)) and three menu set measures (marked with (M)).
• You must choose three core or alternate core measures that do not have a denominator=0.
• (If any of the menu set measures have denominator=0, you must select other measures that do not have denominator=0.)

Clinical Decision Support Rule:

Implement one clinical decision support rule during EHR reporting period.

• This is just a Y/N question asking if you implemented this
• There are any number of items in EHR you could use to do this
• The MU Performance Measure report will look at your RPMS system for you and will automatically answer Y to this question if you have any of the following things configured on your system:
• Clinical Reminders installed and national reminders configured

-OR-

• On the EHR Reports tab: Diabetes, Pre-Diabetes, Asthma, Anti- coagulation, or Women's Health Supplement; Immunization Package Forecasting; and/or Health Maintenance Reminders.

Electronic Copy of Health Information:

>50% of all patients of the EP who request an electronic copy of their health information during the EHR reporting period are provided it within three business days.

• A couple things to note here –
• The logic is looking for “electronic” as the Patient/Agent Request Type and the Record Disseminationfields in the Release of Information Package in RPMS. (If you are not using the ROI package to track requests for ROI, then you will need to track and calculate this measure in another way and have that be very clear in the event of an audit)
• An EP is excluded if there are no requests from a patient for electronic copies of their health information
• If a patient does request an electronic copy of some health information, you will need to have a policy and procedure in place as to how that information can be supplied and how it will be encrypted. IE, on a thumb drive or CD, will the patient provide the electronic device, etc. You will also want to address that when the data is encrypted, a password will be required. You will need to address how password management will be handled, including what to do if the patient forgets the password.
• If a patient requests an electronic copy of health information and you can’t provide it to them within 3 days, you also need to document that in the ROI package.

Clinical Summaries:

Clinical summaries provided to patients for >50% of all office visits within three business days.

• This is a measure that is often confused with other measures
• This one is met by providing the patient with a Patient Wellness Handout containing at least these 4 items: (1) medication list; (2) allergy list; (3) problem list; and (4) lab results.
• Demographics are also required, but are hard coded as part of the PWH, so nothing to worry about there
• There may be additional items on here if you choose
• It does not matter who prints the PWH
• It can’t be printed before the patient checks in for that day – but you do have a window:
• It must be printed on or after the visit date/time but within 3 business days of the visit
• It is perfectly fine to have more than one PWH configured for you system and togenerate more than one throughout the course of the patient’s visit
• *Printing a PWH as part of your clinic routine can help you easily meet one of the Menu Set objectives called Patient Reminders – see below

Electronic Exchange of Clinical Information:

Performed at least one test of certified EHR technology's capacity to electronically exchange key clinical information.

• This is the measure about the C32
• You do not need D1 access to make this work.
• You should be able to generate, view, save, print, etca C32 document from your own EHR.
• The only trouble with D1 may be the transmission of the C32 to the URL in Albuquerque. That is fine for this stage of MU. Eventually, you will be able to pull C32 documents from other sites within IHS and even outside of IHS (local hospital, private doc’s office, etc) and view in your EHR, but this part of the Health Information Exchange is not up and running yet and it is unclear how the D1 issue will be addressed for IHS as a whole. Stay tuned, but don’t worry about it for now.
• The C32 application is installed as part of your certified EHR, however, there is some significant set up that needs to be done in order for the C32 button to function within your EHR
• Your site manager and Area Site Analyst will need to help you get the background set up and the CAC can place the C32 button in the EHR
• To meet the MU measure, you actually only have to perform one test of C32 transmission by following these instructions:
• Step 2 is “Contact the Help Desk and receive the URL of the C32 repository that you will be sending C32s to.” The Help Desk in this case is your Portland Area Site Analyst – they will provide this URL to you
• The test can fail, but it must be completed and documented (via screen shot) at some point prior to the end of the reporting period.
• The test can be done before the reporting period starts, but it will have to be done for each participation year (once for 2011, once for 2012, etc). Since our EPs are using the same EHR in the same location, just one test for the whole facility is sufficient. You may want to put a copy of the screen shot in each EP’s folder.
• See C32 Appendix to this document with some more information

Protect Electronic Health Information:

Conducted or reviewed a security risk analysis of the certified EHR, implemented security updates as necessary and corrected identified security deficiencies as part of risk management process.

• You need to conduct a security risk analysis sometime before the end of your reporting period and review it sometime during your reporting period
• A template developed by OIT is available for this:
• You need to fill out the template and make efforts to correct deficiencies that are found
• Ensure a sanction policy is adopted (required for federal sites; tribal/urban sites may elect to adopt IHS policy). If your site adopts sections from Part 8 of the IHS Manual, in whole or in part and IHS SOPs and appropriate SGMS, this will meet the requirements of adopting a sanction policy
• You can contact Doug Bristow at Portland Area Office with questions about the Security Risk Analysis document:
• Phone # (503) 414-7753

Drug-Formulary Checks:

The EP has enabled this functionality and has access to at least

one internal or external formulary for the entire EHR reporting period.

• This can be an easy one to meet if you have a formulary (even if you don’t have a pharmacy onsite)
• To meet this, you have to have your Clean Date set (see above)
• Then, utilize the field in the drug file to mark drugs as Non-Formulary as appropriate for your site. When the provider enters and order in EHR for a drug marked in this way, a Non Formulary message will appear. That meets this measure. (As a side note, you may also want to populate the formulary alternatives field in the drug file as a handy tool for your providers)
• You just answer Y/N for this measure.

Clinical Lab Test Results:

>40% of all clinical lab results ordered by EP during EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in the certified EHR as structured data.

• If you are using the RPMS lab package and have a bi-directional reference lab interface running, this should be an easy measure to meet
• Having the POC lab button set up and utilized correctly will help you meet this measure as well
• If you do not have the interface or do not have onsite lab, you may not want to choose this measure.

Patient Lists:

Generate at least one report listing the EP’s patients with a specific condition during the EHR reporting period.

• This is another easy one to meet
• You can run any number of reports from RPMS or iCare – including reports from the Women’s Health Package, the Diabetes Audit, the Immunization package, CRS, and QMAN and VGEN reports

Patient Reminders:

>20% of all unique patients who are 0-5 or 65+ years for whom a PWH was printed during the EHR reporting period.

• This one is not about the Clinical Reminders package in EHR – it is about reminding the patient that they are due for some screening or care
• Much like the Clinical Summaries Core measure discussed above, the logic is just looking to see if a PWH was printed for these patients.
• Include the Immunization Due or Cancer Screening components on your PWH and that will meet this measure when it is printed for the patient.
• You can include one (or both) of these items on the PWH that you use for the Clinical Summaries measure and meet this measure at the same time when you print the PWH
• Or, you can have different PWH for different scenarios – whatever fits your clinic workflow the best – what meets these two measures is simply printing a PWH for the patient.
• This is looking at the entire patient population, not patients who had visits necessarily…so having lots of inactive patients whose records have not been inactivated could affect this measure – just something to be aware of.
• Another suggestion that if you are sending out appointment letters or immunization letters, just print the PWH and send it with these letters. This will increase your numbers and help you catch additional patients for this measure.

Patient Electronic Access: At least 10% of all unique patients seen by the EP during the EHR reporting period are provided timely (available within four business days) electronic access to their health information.