Meaningful Use Stage I Class II

1. Meaningful Use Stage IClass II Clinical Quality Measures Shannon Earhart, RRT Sr. Analyst AHIS

2. OBJ-304J Calculate and transmit CMS quality measures • Providers must report to CMS or their state • At least six Clinical Quality Measures • Including 3 Core Measures • 3 Additional Measures

3. Core CQM NQF0421A and B-Adult weight screening and follow-up • The percentage of patients aged 18 years or older and who have had their BMI calculated in the past six months or during the current encounter. If the most recent BMI is outside normal parameters a follow-up plan must be documented • Patients with an active diagnosis of pregnancy are excluded

4. NQF-0421A Adult weight screening and follow-up • Patients 18-64- if BMI is 18.5kg/m2 -25kg/m2 the measure is satisfied. IF BMI is above or below this range, there must be documentation of a care plan or consult.

5. NQF0421B-Adult weight screening and follow-up • Patients 65 or older- If BMI is 22kg/m2 -30kg/m2 the measure is satisfied. If BMI is above or below this range, there must documentation of a care plan or consult • Documentation under Preventative Medicine, MU Objectives category, Provider to Provider or Care Goal follow-up

6. Core CQM NQF-0028A and NQF0028B- Tobacco use and cessation intervention • The percentage of patients 18 years or older that have been asked about their tobacco use at least once in the past two years • Providers must report the percentage of patients aged 18 years or older that have been identified as tobacco users within the past two years who have received tobacco cessation intervention

7. To satisfy this measure:NQF-0038A and NQF0028B- Tobacco use and cessation intervention • Complete tobacco use SmartForm • A tobacco cessation intervention- has been documented within the past two years *Preventative Medicine, MU Objectives, Smoking • A smoking cessation agent medication has been ordered or is active within the past two years

8. Core CQM NQF-0013 Hypertension:B/P measurement • The percentage of patients 18 years or older with an active hypertension diagnosis who have had their blood pressure recorded in at least two outpatient or nursing facility encounters. • Measure is satisfied if patients with hypertension diagnosis have B/P documented in the encounter

9. Alternative Clinical Quality Measures • Substitute one where Core measure denominator is 0

10. NQF-0024 A,D,G Weight assessment and counseling for children • The percentage of patients between the ages of 2 and 17 years • who have had an outpatient visit with their PCP or OB/GYN and • who have evidence of BMI percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year

11. NQF-0024 Weight assessment and counseling for children Satisfying measure: • Preventative Medicine-MU objectives category • To document counseling of BMI-chose either Care Goal follow up plan or provider to provider • To document nutrition counseling and physical activity counseling- chose communication to patient

12. NQF-0041-Influenza Immunization for patients >=50yrs • Providers must report the percentage of patients aged 50 years old or older who have received an Influenza Immunization during the flu season( September-February) • Must chose immunization that has a valid CPT code associated

13. NQF-0038 Childhood immunization status • The percentage of children 2 years of age who have had the following vaccinations by their second birthday • 4 Diphtheria, tetanus and DTap • 3 Polio, one MMR • 2 HiB • 3 Hep B • 1 VZV • 4 PCV • 2 Hep A • 2 or 3 Rotavirus • 2 Influenza

14. NQF-0038 Childhood immunization status • Patients are included in the denominator is >/= to 1 years of age and < 2 yrs of age • Any patient with an allergy or diagnosis contraindicating the immunization is excluded • Must chose immunization with a valid CPT code associated

15. 3 Additional Measures • St. Mary’s Health administration made decision on which three additional measures would be reported • This is for continuity of attestation

16. NQF-0061 Diabetes B/P measurement • The percentage of patients between the ages of 18 and 75 with an active diabetes (Type I or II) diagnosis who have a blood pressure less than 140/90 mmHg • Patients are included in denominator age 17-74 to capture all patients who will reach age 18-75 during reporting period • A medication indicative of diabetes refilled, ordered or listed as active • Active diabetes diagnosis within 2 years of reporting period

17. NQF-0064A and B Diabetes LDL Management and Control • A-The percentage of patients between 18 and 75 with an active diabetes( type I or II) who have an LDL result recorded • B-The percentage of patients between 18 and 75 with an active diabetes( type I or II) who have an LDL result less than 100mg/dL recorded • Patients are included in denominator ages 17-74 to capture all patients who will reach age 18-75 during reporting period • A medication indicative of diabetes refilled, ordered or listed as active • Active diabetes diagnosis within 2 years of reporting period

18. NQF-0064A and B Diabetes LDL Management and Control • Clinician must order and result Low Density LipoProtein –Lipid Panel • (LDL) if first result is >100mg/dL then a follow-up result recorded < 100mg/dL • A Diagnosis of Polycystic ovaries, Gestational diabetes or steroid induced diabetes will exclude the patient

19. NQF-0059 HgB A1C poor control • The percentage of patients between ages 18-75 with an active diabetes (type I or II) diagnosis who have a HbA1c greater than 9.0% • Patients are included in denominator age 17-74 to capture all pts. Who will reach age 18-75 during reporting period • A medication indicative of diabetes refilled, ordered or listed as active • Active diabetes diagnosis within 2 years of reporting period

20. NQF-0059 HgB A1C poor control • Patients in the denominator are included in this numerator if a HbA1c > 9.0% is recorded • A Diagnosis of Polycystic ovaries, Gestational diabetes or steroid induced diabetes within two years before or simultaneous to the reporting period will exclude the patient

21. OBJ304E Implement one clinical decision support rule*Not on MAQ • Implement one clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance of that rule • Provider may wish to enable CDSS in right chart panel for quick review File-settings-my settings-show hide • St. Mary’s Administration made decision on which CDSS measure would be reported • This is for continuity of attestation

22. Smoking Status • Number of patients who have had smoking status identified or updated at least once in the last 12 months up to and including the last day of the reporting period • Tobacco SmartForm

23. PQRI- (G-Code) • Physician Quality Reporting Initiative- May also be called Physician Quality Reporting System(PQRS) • The PQRI is enabled to prompt the G-Code • The G-Code is the reporting tool for Medicare • PQRI-125 eprescribing

24. The END Meaningful Use Class 3 will be covering the 10 Menu Objectives Questions? AHIS Help Desk 812-485-5600