C0Q Quality Reporting 1.0
Contents
What is the Quality Measures Package?
The Quality Measures Package is an addition to VistA for reporting Meaningful Use and Quality Measurements. The package supports both inpatient and outpatient reporting, and computes the Meaningful Use measures from patient records.
For Quality Measurements, the reporting package relies on the VistA Reminders Patient Lists as the source for its reporting.
Licensing
The package is licensed under GPL version 2.0 or later.
http://www.gnu.org/licenses/gpl-2.0.html
Installing C0Q Quality Reporting
System Requirements
- VISTA running on an Mumps 95 compliant implementation
- CCD/CCR GENERATION UTILTIES 1.2
- PXRM*2.0*12
- PXRM*2.0*17
- TMG*1.0*17
Installation of the CCD/CCR Package
The software and documentation for the package is located here
Here are some brief instructions for installing this. Detailed instructions can be found in the above link.
Pre-requisites
Main file installation
Installation of the Quality Measures Package
Pre-requisites
Download and install the following FOIA VISTA patches if you don't already have them installed (they came out in 2009 and 2010).
You also need to install the TMG Growth Charts if you have not already done so.
Main file installation
Download and install the following builds:
IT IS VITAL THAT YOU READ THE README FILES PRIOR TO INSTALLING THE PATCHES. SOME PATCHES WILL WANT LAB TESTS TO BE LINKED. YOU MUST NOT SKIP THIS STEP OTHERWISE YOU WILL BREAK THE REMINDER BEING INSTALLED.
- QUALITY_MEASURES_1P0.KID README
- C0Q-1_SEQ-001_PAT-002.KID README
- C0Q-1_SEQ-002_PAT-003.KID README
- C0Q-1_SEQ-003_PAT-004.KID README
- C0Q-1_SEQ-004_PAT-001.KID README
Installation transcripts can be found in the respective readme files.
Post-installation Tasks
The package does not export any keys at the current time. The package's main menu is C0Q QUALITY MEASUREMENT MENU. A properly configured VISTA user who accesses this menu from their primary or secondary menus will be assumed henceforth. If you intend to place this menu on XUCORE, remember that it doesn't have a key protecting it currently. You will need to make your own.
Configuration of Package
Outpatient Configuration
Here is a summary of what we have to do to make the package work. Right now there are reciprocal dependencies in set-up that require you to go into different options more than once.
Performance Measures Set-Up
- Set-up MU Measure Parameters.
- Create Patient Lists
- Create new MU Utility Measures
- Create a Measure Set containing all your utility measures
- Use specified Reminder Rule Sets and Reminder Extracts to create patient lists in the Reminder Package
- Fill in the names of your created patient lists in the Quality Measures section
- Create a Measure Set containing all your quality measures
- Go back to your parameters and populate the Utility Measure Set and Quality Measure Set
Set-up MU Measure Parameters
Prior to building measures and measure sets, we must establish the parameters. If you’re building outpatient MU measures, “EP EDIT PARMS” should be selected (as seen above). YOU NEED TO CREATE A PARAMETER FOR EACH CLINIC.
From the main menu, choose the SETUP QUALITY REPORTING option.
Select QUALITY MEASUREMENT MENU Option: SETUP QUALITY REPORTING DISPLAY QUALITY MEASURES EDIT SUPERUSERS EP EDIT PARMS INP EDIT PARMS MEASURE SET EDIT MU MEASURE EDIT QUALITY MEASURE EDIT Select SETUP QUALITY REPORTING Option: EP EDIT PARMS Select C0Q PARAMETER NAME: MU DR OFFICE -- Enter Name of Parameter Are you adding 'MU DR OFFICE' as a new C0Q PARAMETER (the 1ST)? No// y (Yes) NAME: MU DR OFFICE Replace MEASUREMENT PERIOD KEY: MU12 -- MUST PUT MU12 HERE OTHERWISE PACKAGE WON'T WORK! PARAMETER TYPE: OUTPATIENT -- Inpatient or Outpatient EP MU MEASUREMENT SET: -- To be left empty for now. Will come back to add measure set. EP QUALITY MEASUREMENT SET: -- To be left empty for now. Will come back to add measure set. Select CLINIC: DR OFFICE DOCTOR,FOUR --defines visit criteria. To ONLY look for visits in a specific clinic, ward, etc. Are you adding 'DR OFFICE' as a new CLINIC (the 1ST for this C0Q PARAMETER)? No// y (Yes) Select CLINIC: -- NOTE: '''Package only support 1 clinic ONLY right now.''' PATIENT LIST LABEL: Select SUBSCRIBER: Select C0Q PARAMETER NAME: ACME CLINIC #1 Are you adding 'ACME CLINIC #1' as a new C0Q PARAMETER (the 2ND)? No// Y (Yes) NAME: ACME CLINIC #1// MEASUREMENT PERIOD KEY: MU12 PARAMETER TYPE: OUT OUTPATIENT EP MU MEASUREMENT SET: EP QUALITY MEASUREMENT SET: Select CLINIC: ACME CLINIC #1 DOCTOR,TEN Are you adding 'ACME CLINIC #1' as a new CLINIC? No// Y (Yes) Select CLINIC: PATIENT LIST LABEL: Select SUBSCRIBER: Select C0Q PARAMETER NAME: ACME CLINIC #2 Are you adding 'ACME CLINIC #2' as a new C0Q PARAMETER (the 3RD)? No// Y (Yes) NAME: ACME CLINIC #2// MEASUREMENT PERIOD KEY: MU12 PARAMETER TYPE: OUT OUTPATIENT EP MU MEASUREMENT SET: EP QUALITY MEASUREMENT SET: Select CLINIC: ACME CLINIC #2 DOCTOR,TEN Are you adding 'ACME CLINIC #2' as a new CLINIC? No// Y (Yes) Select CLINIC: PATIENT LIST LABEL: Select SUBSCRIBER:
Create Patient Lists
After you have created the parameters, you need to have the software create the patient lists. Choose option EP UPDATE MU MEASURES from the parent menu. Once you select “EP UPDATE MU MEASURE” you should see several lines of text (a small subset of this text can be seen above).
Select QUALITY MEASUREMENT MENU Option: EP UPDATE MU MEASURES Jul 25, 2011@98:87:94 Jul 25, 2011@87:88:53 Jun 27, 2011@97:94:70 Jun 27, 2011@97:89:96 BAD HEALTH FACTOR: Non-Smoker (PMH) BAD HEALTH FACTOR: Non-Tobacco User BAD HEALTH FACTOR: Current Smoker - No BAD HEALTH FACTOR: Current Smoker - Yes CREATING MU12-EP-ALL-PATIENTS CREATING MU12-EP-DR OFFICE-Patient CREATING MU12-EP-FailedDemographics CREATING MU12-EP-HasAllergy C0QLIST("MU12-EP-DR OFFICE-Patient",1)="" C0QLIST("MU12-EP-DR OFFICE-Patient",2)="" C0QLIST("MU12-EP-DR OFFICE-Patient",3)="" C0QLIST("MU12-EP-DR OFFICE-Patient",4)="" C0QLIST("MU12-EP-DR OFFICE-Patient",6)="" Oct 04, 2012@91:00C0QLIST("MU12-EP-ACME CLINIC #1-Patient",7)="" C0QLIST("MU12-EP-ALL-PATIENTS",1)="" C0QLIST("MU12-EP-ALL-PATIENTS",2)="" C0QLIST("MU12-EP-ALL-PATIENTS",3)="" C0QLIST("MU12-EP-ALL-PATIENTS",4)="" C0QLIST("MU12-EP-ALL-PATIENTS",6)="" C0QLIST("MU12-EP-DR OFFICE-Patient",1)="" C0QLIST("MU12-EP-DR OFFICE-Patient",2)="" C0QLIST("MU12-EP-DR OFFICE-Patient",3)="" C0QLIST("MU12-EP-DR OFFICE-Patient",4)="" C0QLIST("MU12-EP-DR OFFICE-Patient",6)="" Oct 04, 2012@84:00C0QLIST("MU12-EP-ACME CLINIC #1-Patient",7)="" C0QLIST("MU12-EP-ACME CLINIC #2-Patient",4)="" C0QLIST("MU12-EP-ALL-PATIENTS",1)="" C0QLIST("MU12-EP-ALL-PATIENTS",2)="" C0QLIST("MU12-EP-ALL-PATIENTS",3)="" C0QLIST("MU12-EP-ALL-PATIENTS",4)="" C0QLIST("MU12-EP-ALL-PATIENTS",6)="" C0QLIST("MU12-EP-ALL-PATIENTS",7)="" C0QLIST("MU12-EP-DR OFFICE-Patient",1)="" C0QLIST("MU12-EP-DR OFFICE-Patient",2)="" C0QLIST("MU12-EP-DR OFFICE-Patient",3)="" C0QLIST("MU12-EP-DR OFFICE-Patient",4)="" C0QLIST("MU12-EP-DR OFFICE-Patient",6)="" CREATING MU12-EP-ACME CLINIC #1-Patient CREATING MU12-EP-ACME CLINIC #2-Patient CREATING MU12-EP-NoAllergyB index passed
MOVE MOVE MOVE MOVE
The parameters then update the patient lists associated with the MU measures, creating new lists (lists are auto-generated for MU measures) only if none exist. They then look for MU Measurement Sets that are in the parameters, and update them, copying over numerator and denominator patient lists, counting them, and computing the percentage. A final update should be performed to ensure the most up-to date data is reported for your MU measure/measure set (see step 6).
MOVE MOVE MOVE MOVE
Create new MU Utility Measures
The package distributes the MU Quality Measures; but the Utility measures you have to create on your own. Follow the table below to create the utility measures using option MU MEASURE EDIT. Example of how to enter them are below. If you are doing this for real, make sure to print the table and follow it.
IMPORTANT: There is a bug I just discovered. You need to go back to the menu system and go back into the option (space-bar enter).
# | Measure | Quality Measures Utility Logic | Quality Measures Package Numerator | Quality Measures Package Denominator | Passing Rate |
---|---|---|---|---|---|
1 | CPOE -- Provider directly enters in orders | Check for the presence of electronically prescribed medications stored in the Non-VA Multiple in file 55 for this patient | MU12-EP-HasMedOrders | MU12-EP-ALL-PATIENTS | Rate > 30% |
2 | Implement drug-drug and drug-allergy interaction checks | N/A | N/A | N/A | Report YES. Core VISTA functionality. Also part of electronic prescribing. |
3 | Maintain an up-to-date problem list of current and active diagnoses | Checks active problems. | MU12-EP-HasProblem | MU12-EP-ALL-PATIENTS | Rate > 80% |
4 | Generate and transmit permissible prescriptions electronically (eRx) | Check for the presence of electronically prescribed medications stored in the Non-VA Multiple in file 55 for this patient | MU12-EP-HasERX | MU12-EP-ALL-PATIENTS | Rate > 40% |
5 | Maintain active medication list | Check for the presence of electronically prescribed medications stored in the Non-VA Multiple in file 55 for this patient | MU12-EP-HasMed | MU12-EP-ALL-PATIENTS | Rate > 80% |
6 | Maintain active medication allergy list | Check for the presence of allergy documentation for this patient | MU12-EP-HasAllergy | MU12-EP-ALL-PATIENTS | Rate > 80% |
7 | Record required demographics | Check for the presence of Sex, DOB, Primary ID, Preferred Language, Race, Ethnicity for this patient. Lack of any one disqualifes you. | MU12-EP-HasDemographics | MU12-EP-ALL-PATIENTS | Rate > 50% |
8 | Record required vital signs | Check vital signs from July 3rd 2011 to present for this patient | MU12-EP-HasVitalSigns | MU12-EP-ALL-PATIENTS | Rate > 50% |
9 | Record smoking status for patients aged 13 yrs and up | Check health factors in the category Tobacco; see if patient will have these. If none found in the category, each possible health factor in a list is tried by itself. | MU12-EP-HasSmokingStatus | MU12-EP-Over12 | Rate > 50% |
10 | Report clinical quality measures to CMS | N/A | N/A | N/A | Report YES. Reporting specific Quality Measures will be described later. |
11 | Implement 1 clinical decision support rule | N/A | N/A | N/A | Report YES. If you are doing eRx, using any clinical reminders; or using any order checks, you have met this requirement. |
12 | Provide patients with an electronic copy of their health information | NOT COLLECTIBLE IN VISTA. NO RELEASE OF INFORMATION PACKAGE. COLLECT MANUALLY | N/A | N/A | Rate > 50% |
13 | Provide clinical summaries for patients for each office visit within 3 days | NOT COLLECTIBLE IN VISTA. NO RELEASE OF INFORMATION PACKAGE. COLLECT MANUALLY | N/A | N/A | Rate > 50% |
14 | Perform at least 1 test of exchanging key clinical information with another entity electronically | Not checked. Report YES upon test performance. | N/A | N/A | Not checked. Report YES upon test performance. |
15 | Protect electronic health information | Not checked. Report YES upon test performance. | N/A | N/A | Not checked. Report YES upon test performance. |
Here are the transcripts to do that:
Select SETUP QUALITY REPORTING Option: MU MEASURE EDIT Select C0Q QUALITY MEASURE NAME: MU CORE MEASURE #1 CPOE NAME: MU CORE MEASURE #1// MEASURE TYPE: Performance// MU YEAR KEY: TITLE: VERY LONG DESCRIPTION: THERE ARE NO LINES! Edit? NO// DISPLAY NAME: CPOE// REPORTING NAME: ALTERNATIVE NUMERATOR LIST: MU12-EP-HasMed 1 MU12-EP-HasMed MU12-EP-HasMed 2 MU12-EP-HasMedOrders MU12-EP-HasMedOrders 3 MU12-EP-HasMedRecon MU12-EP-HasMedRecon CHOOSE 1-3: 2 MU12-EP-HasMedOrders MU12-EP-HasMedOrders ALTERNATIVE DENOMINATOR LIST: MU12-EP-ALL-PATIENTS MU12-EP-ALL-PATIENTS Select SETUP QUALITY REPORTING Option: MU MEASURE EDIT Select C0Q QUALITY MEASURE NAME: MU CORE MEASURE #3 Problem List NAME: MU CORE MEASURE #3// MEASURE TYPE: Performance MU YEAR KEY: TITLE: VERY LONG DESCRIPTION: THERE ARE NO LINES! Edit? NO// DISPLAY NAME: Problem List// REPORTING NAME: ALTERNATIVE NUMERATOR LIST: MU12-EP-HasProblem// ALTERNATIVE DENOMINATOR LIST: MU12-EP-ALL-PATIENTS // Select SETUP QUALITY REPORTING Option: MU MEASURE EDIT Select C0Q QUALITY MEASURE NAME: MU CORE MEASURE #4 Are you adding 'MU CORE MEASURE #4' as a new C0Q QUALITY MEASURE (the 91ST)? No// Y (Yes) C0Q QUALITY MEASURE DISPLAY NAME: ERx NAME: MU CORE MEASURE #4// MEASURE TYPE: p Performance MU YEAR KEY: ? Answer must be 1-30 characters in length. MU YEAR KEY: TITLE: VERY LONG DESCRIPTION: THERE ARE NO LINES! Edit? NO// DISPLAY NAME: ERx// REPORTING NAME: ALTERNATIVE NUMERATOR LIST: MU12-EP-HasERX MU12-EP-HasERX ALTERNATIVE DENOMINATOR LIST: MU-EP-ALL?? ALTERNATIVE DENOMINATOR LIST: MU12-EP-ALL-PATIENTS MU12-EP-ALL-PATIENTS Select C0Q QUALITY MEASURE NAME: Select SETUP QUALITY REPORTING Option: MU MEASURE EDIT Select C0Q QUALITY MEASURE NAME: MU CORE MEASURE #5 Are you adding 'MU CORE MEASURE #5' as a new C0Q QUALITY MEASURE (the 92ND)? No// y (Yes) C0Q QUALITY MEASURE DISPLAY NAME: MU12-EP-HasMed NAME: MU CORE MEASURE #5// MEASURE TYPE: MU YEAR KEY: TITLE: VERY LONG DESCRIPTION: THERE ARE NO LINES! Edit? NO// DISPLAY NAME: MU12-EP-HasMed// Active Medication List REPORTING NAME: ALTERNATIVE NUMERATOR LIST: MU12-EP-HasMed 1 MU12-EP-HasMed MU12-EP-HasMed 2 MU12-EP-HasMedOrders MU12-EP-HasMedOrders 3 MU12-EP-HasMedRecon MU12-EP-HasMedRecon CHOOSE 1-3: 1 MU12-EP-HasMed MU12-EP-HasMed ALTERNATIVE DENOMINATOR LIST: MU12-EP-ALL-PATIENTS MU12-EP-ALL-PATIENTS Select C0Q QUALITY MEASURE NAME: Select SETUP QUALITY REPORTING Option: MU MEASURE EDIT Select C0Q QUALITY MEASURE NAME: MU CORE MEASURE #6 Are you adding 'MU CORE MEASURE #6' as a new C0Q QUALITY MEASURE (the 93RD)? No// y (Yes) C0Q QUALITY MEASURE DISPLAY NAME: Allergy Documentation NAME: MU CORE MEASURE #6// MEASURE TYPE: MU YEAR KEY: ^meas,typ MEASURE TYPE MEASURE TYPE: p Performance MU YEAR KEY: TITLE: VERY LONG DESCRIPTION: THERE ARE NO LINES! Edit? NO// DISPLAY NAME: Allergy Documentation Replace REPORTING NAME: ALTERNATIVE NUMERATOR LIST: MU12-EP-Has 1 MU12-EP-HasAllergy MU12-EP-HasAllergy 2 MU12-EP-HasDemographics MU12-EP-HasDemographics 3 MU12-EP-HasERX MU12-EP-HasERX 4 MU12-EP-HasMed MU12-EP-HasMed 5 MU12-EP-HasMedOrders MU12-EP-HasMedOrders Press <Enter> to see more, '^' to exit this list, OR CHOOSE 1-5: 1 MU12-EP-HasAllergy MU12-EP-HasAllergy ALTERNATIVE DENOMINATOR LIST: MU12-EP-ALL-PATIENTS MU12-EP-ALL-PATIENTS Select C0Q QUALITY MEASURE NAME: Select SETUP QUALITY REPORTING Option: MU MEASURE EDIT Select C0Q QUALITY MEASURE NAME: MU CORE MEASURE #7 Are you adding 'MU CORE MEASURE #7' as a new C0Q QUALITY MEASURE (the 94TH)? No// y (Yes) C0Q QUALITY MEASURE DISPLAY NAME: Required Demographics Present? NAME: MU CORE MEASURE #7// MEASURE TYPE: p Performance MU YEAR KEY: TITLE: VERY LONG DESCRIPTION: THERE ARE NO LINES! Edit? NO// DISPLAY NAME: Required Demographics Present? Replace REPORTING NAME: ALTERNATIVE NUMERATOR LIST: MU12-EP-HasDemographics MU12-EP-HasDemographic s ALTERNATIVE DENOMINATOR LIST: MU12-EP-ALL-PATIENTS MU12-EP-ALL-PATIENTS Select C0Q QUALITY MEASURE NAME: Select SETUP QUALITY REPORTING Option: MU MEASURE EDIT Select C0Q QUALITY MEASURE NAME: MU CORE MEASURE #8 Are you adding 'MU CORE MEASURE #8' as a new C0Q QUALITY MEASURE (the 95TH)? No// y (Yes) C0Q QUALITY MEASURE DISPLAY NAME: MU12-EP-HasVitalSigns NAME: MU CORE MEASURE #8// MEASURE TYPE: p Performance MU YEAR KEY: TITLE: VERY LONG DESCRIPTION: THERE ARE NO LINES! Edit? NO// DISPLAY NAME: MU12-EP-HasVitalSigns Replace ... With Record Vital Signs Replace Record Vital Signs REPORTING NAME: ALTERNATIVE NUMERATOR LIST: MU12-EP-HasVitalSigns MU12-EP-HasVitalSigns ALTERNATIVE DENOMINATOR LIST: MU12-EP-ALL-PATIENTS MU12-EP-ALL-PATIENTS Select C0Q QUALITY MEASURE NAME: MU CORE MEASURE #9 ?? Select C0Q QUALITY MEASURE NAME: Select SETUP QUALITY REPORTING Option: MU MEASURE EDIT Select C0Q QUALITY MEASURE NAME: MU CORE MEASURE #9 Are you adding 'MU CORE MEASURE #9' as a new C0Q QUALITY MEASURE (the 96TH)? No// Y (Yes) C0Q QUALITY MEASURE DISPLAY NAME: Record Smoking Status NAME: MU CORE MEASURE #9// MEASURE TYPE: p Performance MU YEAR KEY: TITLE: VERY LONG DESCRIPTION: THERE ARE NO LINES! Edit? NO// DISPLAY NAME: Record Smoking Status Replace REPORTING NAME: ALTERNATIVE NUMERATOR LIST: MU12-EP-HasSmokingStatus MU12-EP-HasSmokingSta tus ALTERNATIVE DENOMINATOR LIST: MU12-Over?? ALTERNATIVE DENOMINATOR LIST: MU12-EP-Over12 MU12-EP-Over12
Create MU Measure SET and add MU Measure(s)
Now for each clinic parameter you set-up, you need to set-up a Measurement Set. Each Measurement Set is what is used to report the clinic's performance.
Select SETUP QUALITY REPORTING Option: MEASURE SET EDIT Select C0Q MEASUREMENT SET NAME: DR OFFICE CLINIC REPORT Are you adding 'DR OFFICE CLINIC REPORT' as a new C0Q MEASUREMENT SET (the 11TH)? No// Y (Yes) NAME: DR OFFICE CLINIC REPORT// BEGIN DATE: 8/1 (AUG 01, 2012) END DATE: 10/31 (OCT 31, 2012) LOCKED: MU YEAR KEY: QRDA TEMPLATE ROOT: Select MEASURE: MU,C,1 MU CORE MEASURE #1 CPOE Are you adding 'MU CORE MEASURE #1' as a new MEASURE? No// Y (Yes) NUMERATOR FILTER LIST: MU,DR MU12-EP-DR OFFICE-Patient MU12-EP-DR OFFICE- Patient DENOMINATOR FILTER LIST: MU12-EP-DR OFFICE-Patient MU12-EP-DR OFFICE-Pa tient Select MEASURE: MU,C,2 MU 2011 INP CPOE CPOE for Medications Are you adding 'MU 2011 INP CPOE' as a new MEASURE? No// N (No) ?? Select MEASURE: MU,C,3 MU CORE MEASURE #3 Problem List Are you adding 'MU CORE MEASURE #3' as a new MEASURE? No// Y (Yes) NUMERATOR FILTER LIST: MU12-EP-DR OFFICE-Patient MU12-EP-DR OFFICE-Pati ent DENOMINATOR FILTER LIST: MU12-EP-DR OFFICE-Patient MU12-EP-DR OFFICE-Pa tient Select MEASURE: MU,C,4 MU CORE MEASURE #4 ERx Are you adding 'MU CORE MEASURE #4' as a new MEASURE? No// Y (Yes) NUMERATOR FILTER LIST: MU12-EP-DR OFFICE-Patient MU12-EP-DR OFFICE-Pati ent DENOMINATOR FILTER LIST: MU12-EP-DR OFFICE-Patient MU12-EP-DR OFFICE-Pa tient Select MEASURE: MU,C,5 MU CORE MEASURE #5 Active Medication List Are you adding 'MU CORE MEASURE #5' as a new MEASURE? No// Y (Yes) NUMERATOR FILTER LIST: MU12-EP-DR OFFICE-Patient MU12-EP-DR OFFICE-Pati ent DENOMINATOR FILTER LIST: MU12-EP-DR OFFICE-Patient MU12-EP-DR OFFICE-Pa tient Select MEASURE: MU,C,6 MU CORE MEASURE #6 Allergy Documentation Are you adding 'MU CORE MEASURE #6' as a new MEASURE? No// Y (Yes) NUMERATOR FILTER LIST: MU12-EP-DR OFFICE-Patient MU12-EP-DR OFFICE-Pati ent DENOMINATOR FILTER LIST: MU12-EP-DR OFFICE-Patient MU12-EP-DR OFFICE-Pa tient Select MEASURE: MU,C,7 MU CORE MEASURE #7 Required Demographics Present? Are you adding 'MU CORE MEASURE #7' as a new MEASURE? No// Y (Yes) NUMERATOR FILTER LIST: MU12-EP-DR OFFICE-Patient MU12-EP-DR OFFICE-Pati ent DENOMINATOR FILTER LIST: MU12-EP-DR OFFICE-Patient MU12-EP-DR OFFICE-Pa tient Select MEASURE: MU,C,8 MU CORE MEASURE #8 Record Vital Signs Are you adding 'MU CORE MEASURE #8' as a new MEASURE? No// Y (Yes) NUMERATOR FILTER LIST: MU12-EP-DR OFFICE-Patient MU12-EP-DR OFFICE-Pati ent DENOMINATOR FILTER LIST: MU12-EP-DR OFFICE-Patient MU12-EP-DR OFFICE-Pa tient Select MEASURE: MU,C,9 MU CORE MEASURE #9 Record Smoking Status Are you adding 'MU CORE MEASURE #9' as a new MEASURE? No// Y (Yes) NUMERATOR FILTER LIST: MU12-EP-DR OFFICE-Patient MU12-EP-DR OFFICE-Pati ent DENOMINATOR FILTER LIST: MU12-EP-DR OFFICE-Patient MU12-EP-DR OFFICE-Pa tient Select MEASURE: Select C0Q MEASUREMENT SET NAME: ACME CLINIC #1 REPORT Are you adding 'ACME CLINIC #1 REPORT' as a new C0Q MEASUREMENT SET (the 12TH)? No// Y (Yes) NAME: ACME CLINIC #1 REPORT Replace BEGIN DATE: 8/1 (AUG 01, 2012) END DATE: 10/31 (OCT 31, 2012) LOCKED: MU YEAR KEY: QRDA TEMPLATE ROOT: Select MEASURE: MU,C,1 MU CORE MEASURE #1 CPOE Are you adding 'MU CORE MEASURE #1' as a new MEASURE? No// Y (Yes) NUMERATOR FILTER LIST: MU,ACME,1 MU12-EP-ACME CLINIC #1-Patient MU12-EP-A CME CLINIC #1-Patient DENOMINATOR FILTER LIST: MU12-EP-ACME CLINIC #1-Patient MU12-EP-ACME CL INIC #1-Patient Select MEASURE: MU,C,3 MU CORE MEASURE #3 Problem List Are you adding 'MU CORE MEASURE #3' as a new MEASURE? No// Y (Yes) NUMERATOR FILTER LIST: MU12-EP-ACME CLINIC #1-Patient MU12-EP-ACME CLIN IC #1-Patient DENOMINATOR FILTER LIST: MU12-EP-ACME CLINIC #1-Patient MU12-EP-ACME CL INIC #1-Patient Select MEASURE: MU,C,4 MU CORE MEASURE #4 ERx Are you adding 'MU CORE MEASURE #4' as a new MEASURE? No// Y (Yes) NUMERATOR FILTER LIST: MU12-EP-ACME CLINIC #1-Patient MU12-EP-ACME CLIN IC #1-Patient DENOMINATOR FILTER LIST: MU12-EP-ACME CLINIC #1-Patient MU12-EP-ACME CL INIC #1-Patient Select MEASURE: MU,C,5 MU CORE MEASURE #5 Active Medication List Are you adding 'MU CORE MEASURE #5' as a new MEASURE? No// Y (Yes) NUMERATOR FILTER LIST: MU12-EP-ACME CLINIC #1-Patient MU12-EP-ACME CLIN IC #1-Patient DENOMINATOR FILTER LIST: MU12-EP-ACME CLINIC #1-Patient MU12-EP-ACME CL INIC #1-Patient Select MEASURE: MU,C,6 MU CORE MEASURE #6 Allergy Documentation Are you adding 'MU CORE MEASURE #6' as a new MEASURE? No// Y (Yes) NUMERATOR FILTER LIST: MU12-EP-ACME CLINIC #1-Patient MU12-EP-ACME CLIN IC #1-Patient DENOMINATOR FILTER LIST: MU12-EP-ACME CLINIC #1-Patient MU12-EP-ACME CL INIC #1-Patient Select MEASURE: MU,C,7 MU CORE MEASURE #7 Required Demographics Present? Are you adding 'MU CORE MEASURE #7' as a new MEASURE? No// Y (Yes) NUMERATOR FILTER LIST: MU12-EP-ACME CLINIC #1-Patient MU12-EP-ACME CLIN IC #1-Patient DENOMINATOR FILTER LIST: MU12-EP-ACME CLINIC #1-Patient MU12-EP-ACME CL INIC #1-Patient Select MEASURE: MU,C,8 MU CORE MEASURE #8 Record Vital Signs Are you adding 'MU CORE MEASURE #8' as a new MEASURE? No// Y (Yes) NUMERATOR FILTER LIST: MU12-EP-ACME CLINIC #1-Patient MU12-EP-ACME CLIN IC #1-Patient DENOMINATOR FILTER LIST: MU12-EP-ACME CLINIC #1-Patient MU12-EP-ACME CL INIC #1-Patient Select MEASURE: MU,C,9 MU CORE MEASURE #9 Record Smoking Status Are you adding 'MU CORE MEASURE #9' as a new MEASURE? No// Y (Yes) NUMERATOR FILTER LIST: MU12-EP-ACME CLINIC #1-Patient MU12-EP-ACME CLIN IC #1-Patient DENOMINATOR FILTER LIST: MU12-EP-ACME CLINIC #1-Patient MU12-EP-ACME CL INIC #1-Patient Select MEASURE: Select C0Q MEASUREMENT SET NAME: ACME CLINIC #2 REPORT Are you adding 'ACME CLINIC #2 REPORT' as a new C0Q MEASUREMENT SET (the 13TH)? No// Y (Yes) NAME: ACME CLINIC #2 REPORT Replace BEGIN DATE: 8/1 (AUG 01, 2012) END DATE: 10/31 (OCT 31, 2012) LOCKED: MU YEAR KEY: QRDA TEMPLATE ROOT: Select MEASURE: MU,C,1 MU CORE MEASURE #1 CPOE Are you adding 'MU CORE MEASURE #1' as a new MEASURE? No// Y (Yes) NUMERATOR FILTER LIST: MU,ACME,2 MU12-EP-ACME CLINIC #2-Patient MU12-EP-A CME CLINIC #2-Patient DENOMINATOR FILTER LIST: MU12-EP-ACME CLINIC #2-Patient MU12-EP-ACME CL INIC #2-Patient Select MEASURE: MU,C,3 MU CORE MEASURE #3 Problem List Are you adding 'MU CORE MEASURE #3' as a new MEASURE? No// Y (Yes) NUMERATOR FILTER LIST: MU12-EP-ACME CLINIC #2-Patient MU12-EP-ACME CLIN IC #2-Patient DENOMINATOR FILTER LIST: MU12-EP-ACME CLINIC #2-Patient MU12-EP-ACME CL INIC #2-Patient Select MEASURE: MU,C,4 MU CORE MEASURE #4 ERx Are you adding 'MU CORE MEASURE #4' as a new MEASURE? No// Y (Yes) NUMERATOR FILTER LIST: MU12-EP-ACME CLINIC #2-Patient MU12-EP-ACME CLIN IC #2-Patient DENOMINATOR FILTER LIST: MU12-EP-ACME CLINIC #2-Patient MU12-EP-ACME CL INIC #2-Patient Select MEASURE: MU,C,5 MU CORE MEASURE #5 Active Medication List Are you adding 'MU CORE MEASURE #5' as a new MEASURE? No// Y (Yes) NUMERATOR FILTER LIST: MU12-EP-ACME CLINIC #2-Patient MU12-EP-ACME CLIN IC #2-Patient DENOMINATOR FILTER LIST: MU12-EP-ACME CLINIC #2-Patient MU12-EP-ACME CL INIC #2-Patient Select MEASURE: MU,C,6 MU CORE MEASURE #6 Allergy Documentation Are you adding 'MU CORE MEASURE #6' as a new MEASURE? No// Y (Yes) NUMERATOR FILTER LIST: MU12-EP-ACME CLINIC #2-Patient MU12-EP-ACME CLIN IC #2-Patient DENOMINATOR FILTER LIST: MU12-EP-ACME CLINIC #2-Patient MU12-EP-ACME CL INIC #2-Patient Select MEASURE: MU,C,7 MU CORE MEASURE #7 Required Demographics Present? Are you adding 'MU CORE MEASURE #7' as a new MEASURE? No// Y (Yes) NUMERATOR FILTER LIST: MU12-EP-ACME CLINIC #2-Patient MU12-EP-ACME CLIN IC #2-Patient DENOMINATOR FILTER LIST: MU12-EP-ACME CLINIC #2-Patient MU12-EP-ACME CL INIC #2-Patient Select MEASURE: MU,C,8 MU CORE MEASURE #8 Record Vital Signs Are you adding 'MU CORE MEASURE #8' as a new MEASURE? No// Y (Yes) NUMERATOR FILTER LIST: Y?? NUMERATOR FILTER LIST: MU12-EP-ACME CLINIC #2-Patient MU12-EP-ACME CLIN IC #2-Patient DENOMINATOR FILTER LIST: MU12-EP-ACME CLINIC #2-Patient MU12-EP-ACME CL INIC #2-Patient Select MEASURE: MU,C,9 MU CORE MEASURE #9 Record Smoking Status Are you adding 'MU CORE MEASURE #9' as a new MEASURE? No// Y (Yes) NUMERATOR FILTER LIST: MU12-EP-ACME CLINIC #2-Patient MU12-EP-ACME CLIN IC #2-Patient DENOMINATOR FILTER LIST: MU12-EP-ACME CLINIC #2-Patient MU12-EP-ACME CL INIC #2-Patient Select MEASURE:
Update Parameters with the Measure Sets
Now attach the Utility Measure Sets into the parameters.
Select SETUP QUALITY REPORTING Option: EP EDIT PARMS Select C0Q PARAMETER NAME: ?? Choose from: ACME CLINIC #1 ACME CLINIC #2 MU DR OFFICE You may enter a new C0Q PARAMETER, if you wish Select C0Q PARAMETER NAME: MU DR OFFICE NAME: MU DR OFFICE// MEASUREMENT PERIOD KEY: MU12// PARAMETER TYPE: OUTPATIENT// EP MU MEASUREMENT SET: DR OFFICE CLINIC REPORT EP QUALITY MEASUREMENT SET: Select CLINIC: DR OFFICE// PATIENT LIST LABEL: Select SUBSCRIBER: Select C0Q PARAMETER NAME: ACME CLINIC #1 NAME: ACME CLINIC #1// MEASUREMENT PERIOD KEY: MU12// PARAMETER TYPE: OUTPATIENT// EP MU MEASUREMENT SET: ACME,1 ACME CLINIC #1 REPORT EP QUALITY MEASUREMENT SET: Select CLINIC: ACME CLINIC #1// PATIENT LIST LABEL: Select SUBSCRIBER: Select C0Q PARAMETER NAME: ACME CLINIC #2 NAME: ACME CLINIC #2// MEASUREMENT PERIOD KEY: MU12// PARAMETER TYPE: OUTPATIENT// EP MU MEASUREMENT SET: ACME,2 ACME CLINIC #2 REPORT EP QUALITY MEASUREMENT SET: Select CLINIC: ACME CLINIC #2// PATIENT LIST LABEL: Select SUBSCRIBER:
Update MU Measure(s)
To populate the data for the reports, now you need to go back and run EP UPDATE MU MEASURES. Everytime you run this, it will update the data from the system.
Select QUALITY MEASUREMENT MENU Option: ep update MU MEASURES Oct 03, 2012@91:70 Oct 03, 2012@82:92:71C0QLIST("MU12-EP-DR OFFICE-Patient",4)="" C0QLIST("MU12-EP-DR OFFICE-Patient",6)="" Oct 04, 2012@91:00C0QLIST("MU12-EP-ACME CLINIC #1-Patient",7)="" C0QLIST("MU12-EP-ALL-PATIENTS",4)="" C0QLIST("MU12-EP-ALL-PATIENTS",6)="" C0QLIST("MU12-EP-DR OFFICE-Patient",4)="" C0QLIST("MU12-EP-DR OFFICE-Patient",6)="" Oct 04, 2012@84:00C0QLIST("MU12-EP-ACME CLINIC #1-Patient",7)="" C0QLIST("MU12-EP-ACME CLINIC #2-Patient",4)="" C0QLIST("MU12-EP-ALL-PATIENTS",4)="" C0QLIST("MU12-EP-ALL-PATIENTS",6)="" C0QLIST("MU12-EP-ALL-PATIENTS",7)="" C0QLIST("MU12-EP-DR OFFICE-Patient",4)="" C0QLIST("MU12-EP-DR OFFICE-Patient",6)="" B index passed 6 Calling GETMEDS6 SOAP Web Service Call for 6 Patient 6 Rx 1 DeaClassCode: 0 PharmacyType: 0 Patient 6 Rx 2 DeaClassCode: 0 PharmacyType: 0 Patient 6 Rx 3 DeaClassCode: 0 PharmacyType: 0 Patient 6 Rx 4 DeaClassCode: 0 PharmacyType: 0 IENs ?+16,1,11, ready to file Saving ERXDEN of 0 for Patient RUNNER,ROAD (6) Fileman Data Array C0QFDA(1130580001.3111,"?+16,1,11,",.01): ERXDEN C0QFDA(1130580001.3111,"?+16,1,11,",.02): 0 Patient 6 Rx 1 DeaClassCode: 0 PharmacyType: 0 Patient 6 Rx 2 DeaClassCode: 0 PharmacyType: 0 Patient 6 Rx 3 DeaClassCode: 0 PharmacyType: 0 Patient 6 Rx 4 DeaClassCode: 0 PharmacyType: 0 IENs ?+16,1,11, ready to file Saving ERXNUM of 0 for Patient RUNNER,ROAD (6) Fileman Data Array C0QFDA(1130580001.3111,"?+16,1,11,",.01): ERXNUM C0QFDA(1130580001.3111,"?+16,1,11,",.02): 0 C0QFDA(1130580001.2011,"1,14,",1.1)=1 C0QFDA(1130580001.20111,"+1,1,14,",.01)=6 C0QFDA(1130580001.2011,"1,14,",2.1)=2 C0QFDA(1130580001.20112,"+1,1,14,",.01)=4 C0QFDA(1130580001.20112,"+2,1,14,",.01)=6 C0QFDA(1130580001.2011,"1,14,",3)=50 C0QFDA(1130580001.2011,"2,14,",1.1)=1 C0QFDA(1130580001.20111,"+1,2,14,",.01)=4 C0QFDA(1130580001.2011,"2,14,",2.1)=2 C0QFDA(1130580001.20112,"+1,2,14,",.01)=4 C0QFDA(1130580001.20112,"+2,2,14,",.01)=6 C0QFDA(1130580001.2011,"2,14,",3)=50 C0QFDA(1130580001.2011,"3,14,",1.1)=1 C0QFDA(1130580001.20111,"+1,3,14,",.01)=6 C0QFDA(1130580001.2011,"3,14,",2.1)=2 C0QFDA(1130580001.20112,"+1,3,14,",.01)=4 C0QFDA(1130580001.20112,"+2,3,14,",.01)=6 C0QFDA(1130580001.2011,"3,14,",3)=50 C0QFDA(1130580001.2011,"4,14,",1.1)=1 C0QFDA(1130580001.20111,"+1,4,14,",.01)=6 C0QFDA(1130580001.2011,"4,14,",2.1)=2 C0QFDA(1130580001.20112,"+1,4,14,",.01)=4 C0QFDA(1130580001.20112,"+2,4,14,",.01)=6 C0QFDA(1130580001.2011,"4,14,",3)=50 C0QFDA(1130580001.2011,"5,14,",1.1)=2 C0QFDA(1130580001.20111,"+1,5,14,",.01)=4 C0QFDA(1130580001.20111,"+2,5,14,",.01)=6 C0QFDA(1130580001.2011,"5,14,",2.1)=2 C0QFDA(1130580001.20112,"+1,5,14,",.01)=4 C0QFDA(1130580001.20112,"+2,5,14,",.01)=6 C0QFDA(1130580001.2011,"5,14,",3)=100 C0QFDA(1130580001.2011,"6,14,",1.1)=2 C0QFDA(1130580001.20111,"+1,6,14,",.01)=4 C0QFDA(1130580001.20111,"+2,6,14,",.01)=6 C0QFDA(1130580001.2011,"6,14,",2.1)=2 C0QFDA(1130580001.20112,"+1,6,14,",.01)=4 C0QFDA(1130580001.20112,"+2,6,14,",.01)=6 C0QFDA(1130580001.2011,"6,14,",3)=100 C0QFDA(1130580001.2011,"7,14,",1.1)=2 C0QFDA(1130580001.20111,"+1,7,14,",.01)=4 C0QFDA(1130580001.20111,"+2,7,14,",.01)=6 C0QFDA(1130580001.2011,"7,14,",2.1)=2 C0QFDA(1130580001.20112,"+1,7,14,",.01)=4 C0QFDA(1130580001.20112,"+2,7,14,",.01)=6 C0QFDA(1130580001.2011,"7,14,",3)=100 C0QFDA(1130580001.2011,"8,14,",1.1)=1 C0QFDA(1130580001.20111,"+1,8,14,",.01)=4 C0QFDA(1130580001.2011,"8,14,",2.1)=1 C0QFDA(1130580001.20112,"+1,8,14,",.01)=4 C0QFDA(1130580001.2011,"8,14,",3)=100 C0QFDA(1130580001.2011,"1,15,",1.1)=0 C0QFDA(1130580001.2011,"1,15,",2.1)=1 C0QFDA(1130580001.20112,"+1,1,15,",.01)=7 C0QFDA(1130580001.2011,"1,15,",3)=0 C0QFDA(1130580001.2011,"2,15,",1.1)=0 C0QFDA(1130580001.2011,"2,15,",2.1)=1 C0QFDA(1130580001.20112,"+1,2,15,",.01)=7 C0QFDA(1130580001.2011,"2,15,",3)=0 C0QFDA(1130580001.2011,"3,15,",1.1)=0 C0QFDA(1130580001.2011,"3,15,",2.1)=1 C0QFDA(1130580001.20112,"+1,3,15,",.01)=7 C0QFDA(1130580001.2011,"3,15,",3)=0 C0QFDA(1130580001.2011,"4,15,",1.1)=0 C0QFDA(1130580001.2011,"4,15,",2.1)=1 C0QFDA(1130580001.20112,"+1,4,15,",.01)=7 C0QFDA(1130580001.2011,"4,15,",3)=0 C0QFDA(1130580001.2011,"5,15,",1.1)=0 C0QFDA(1130580001.2011,"5,15,",2.1)=1 C0QFDA(1130580001.20112,"+1,5,15,",.01)=7 C0QFDA(1130580001.2011,"5,15,",3)=0 C0QFDA(1130580001.2011,"6,15,",1.1)=1 C0QFDA(1130580001.20111,"+1,6,15,",.01)=7 C0QFDA(1130580001.2011,"6,15,",2.1)=1 C0QFDA(1130580001.20112,"+1,6,15,",.01)=7 C0QFDA(1130580001.2011,"6,15,",3)=100 C0QFDA(1130580001.2011,"7,15,",1.1)=0 C0QFDA(1130580001.2011,"7,15,",2.1)=1 C0QFDA(1130580001.20112,"+1,7,15,",.01)=7 C0QFDA(1130580001.2011,"7,15,",3)=0 C0QFDA(1130580001.2011,"8,15,",1.1)=1 C0QFDA(1130580001.20111,"+1,8,15,",.01)=7 C0QFDA(1130580001.2011,"8,15,",2.1)=1 C0QFDA(1130580001.20112,"+1,8,15,",.01)=7 C0QFDA(1130580001.2011,"8,15,",3)=100 C0QFDA(1130580001.2011,"1,16,",1.1)=0 C0QFDA(1130580001.2011,"1,16,",2.1)=1 C0QFDA(1130580001.20112,"+1,1,16,",.01)=4 C0QFDA(1130580001.2011,"1,16,",3)=0 C0QFDA(1130580001.2011,"2,16,",1.1)=1 C0QFDA(1130580001.20111,"+1,2,16,",.01)=4 C0QFDA(1130580001.2011,"2,16,",2.1)=1 C0QFDA(1130580001.20112,"+1,2,16,",.01)=4 C0QFDA(1130580001.2011,"2,16,",3)=100 C0QFDA(1130580001.2011,"3,16,",1.1)=0 C0QFDA(1130580001.2011,"3,16,",2.1)=1 C0QFDA(1130580001.20112,"+1,3,16,",.01)=4 C0QFDA(1130580001.2011,"3,16,",3)=0 C0QFDA(1130580001.2011,"4,16,",1.1)=0 C0QFDA(1130580001.2011,"4,16,",2.1)=1 C0QFDA(1130580001.20112,"+1,4,16,",.01)=4 C0QFDA(1130580001.2011,"4,16,",3)=0 C0QFDA(1130580001.2011,"5,16,",1.1)=1 C0QFDA(1130580001.20111,"+1,5,16,",.01)=4 C0QFDA(1130580001.2011,"5,16,",2.1)=1 C0QFDA(1130580001.20112,"+1,5,16,",.01)=4 C0QFDA(1130580001.2011,"5,16,",3)=100 C0QFDA(1130580001.2011,"6,16,",1.1)=1 C0QFDA(1130580001.20111,"+1,6,16,",.01)=4 C0QFDA(1130580001.2011,"6,16,",2.1)=1 C0QFDA(1130580001.20112,"+1,6,16,",.01)=4 C0QFDA(1130580001.2011,"6,16,",3)=100 C0QFDA(1130580001.2011,"7,16,",1.1)=1 C0QFDA(1130580001.20111,"+1,7,16,",.01)=4 C0QFDA(1130580001.2011,"7,16,",2.1)=1 C0QFDA(1130580001.20112,"+1,7,16,",.01)=4 C0QFDA(1130580001.2011,"7,16,",3)=100 C0QFDA(1130580001.2011,"8,16,",1.1)=1 C0QFDA(1130580001.20111,"+1,8,16,",.01)=4 C0QFDA(1130580001.2011,"8,16,",2.1)=1 C0QFDA(1130580001.20112,"+1,8,16,",.01)=4 C0QFDA(1130580001.2011,"8,16,",3)=100 Select QUALITY MEASUREMENT MENU Option:
Print C0Q Measures
Print the measures now. You are now done for the Utility Measures.
Select QUALITY MEASUREMENT MENU Option: PRINT C0Q MEASURES Select C0Q MEASUREMENT SET NAME: DR OFFICE CLINIC REPORT DEVICE: PHOME HOME PRINTER C0Q MEASUREMENTS LIST OCT 5,2012@14:22 PAGE 1 MEASURE:DISPLAY NAME DENOMINATOR NUMERATOR PERCENTAGE -------------------------------------------------------------------------------- CPOE 2 1 50.00 Problem List 2 1 50.00 ERx 2 1 50.00 Active Medication List 2 1 50.00 Allergy Documentation 2 2 100.00 Required Demographics 2 2 100.00 Present? Record Vital Signs 2 2 100.00 Record Smoking Status 1 1 100.00 Select C0Q MEASUREMENT SET NAME: ACME CLINIC #1 REPORT DEVICE: PHOME HOME PRINTER C0Q MEASUREMENTS LIST OCT 5,2012@14:22 PAGE 1 MEASURE:DISPLAY NAME DENOMINATOR NUMERATOR PERCENTAGE -------------------------------------------------------------------------------- CPOE 1 0 0.00 Problem List 1 0 0.00 ERx 1 0 0.00 Active Medication List 1 0 0.00 Allergy Documentation 1 0 0.00 Required Demographics 1 1 100.00 Present? Record Vital Signs 1 0 0.00 Record Smoking Status 1 1 100.00 Select C0Q MEASUREMENT SET NAME: ACME CLINIC #2 REPORT DEVICE: PHOME HOME PRINTER C0Q MEASUREMENTS LIST OCT 5,2012@14:23 PAGE 1 MEASURE:DISPLAY NAME DENOMINATOR NUMERATOR PERCENTAGE -------------------------------------------------------------------------------- CPOE 1 0 0.00 Problem List 1 1 100.00 ERx 1 0 0.00 Active Medication List 1 0 0.00 Allergy Documentation 1 1 100.00 Required Demographics 1 1 100.00 Present? Record Vital Signs 1 1 100.00 Record Smoking Status 1 1 100.00
Quality Measures Set-Up
The following two tables are the Rosetta Stone. I would recommend that you print these prior to setting up the package.
Quality Measures supported by the package:
Measure | Human Name | Type | Name in VISTA | How to Generate Counts in VISTA |
---|---|---|---|---|
NQF0013 | Hypertenstion | Core | MU EP NQF 0013 | Reminder Rule Sets |
NQF0028A | Tobacco Screen | Core | MU EP NQF 0028A | Reminder Rule Sets |
NQF0028B | Tobacco Intervention | Core | MU EP NQF 0028B | Reminder Rule Sets |
NQF0421 | Adult BMI | Core | MU EP NQF 0421 | Reminder Extract |
NQF0024A | Children BMI 11-17 | Alternate Core | MU EP NQF 0024 11-17Y | Reminder Rule Sets |
NQF0024B | Children BMI 2-10 | Alternate Core | MU EP NQF 0024 2-10Y | Reminder Rule Sets |
NQF0041 | Flu Vaccination | Alternate Core | MU EP NQF 0041 | Reminder Rule Sets |
NQF0038 | Infants' Immunizations | Alternate Core | various | Reminder Extract |
NQF0059 | DM: A1C Control | Additional | MU EP NQF 0059 | Reminder Rule Sets |
NQF0061 | DM: LDL Control | Additional | MU EP NQF 0061 | Reminder Rule Sets |
NQF0064 | DM: BP Control | Additional | MU EP NQF 0064 | Reminder Rule Sets |
C0Q QUALITY MEASURE List NAME NUMERATOR RULE SET DENOMINATOR RULE SET EXTRACT DEFINITION ---------------------------------------------------------------------------------------------------------------------------------------------- MU EP NQF 0013 MU NQF0013 HTN NUMER2 RS MU NQF0013 HTN DENOM2 RS MU EP NQF 0024 MU NQF0024 BMI 2-17YR NUM RS MU NQF0024 BMI 2-17YRS DEM RS MU EP NQF 0024 11-17Y MU NQF0024 BMI PERCENTILE 11-17Y RS MU NQF0024 BMI 11-17Y DENOM RS MU EP NQF 0024 2-10Y MU NQF0024 BMI PERCENTILE 2-10Y RS MU NQF0024 BMI 2-10Y DENOM RS MU EP NQF 0028A MU NQF0028A TOBACCO SCREEN NUM RS MU NQF0028B TOBACCO INTERV DENOM RS MU EP NQF 0028B MU NQF0028B TOBACCO INTERV NUM2 RS MU NQF0028B TOBACCO INTERV DENOM RS MU EP NQF 0038 NUM1 DPT MU NQF0038 NUM1 DPT RS MU NQF0038 DENOM RS MU NQF0038 CHILDREN'S IMMUNIZATIONS MU EP NQF 0038 NUM10 FLU MU NQF0038 NUM10 INFLUENZA RS MU NQF0038 DENOM RS MU NQF0038 CHILDREN'S IMMUNIZATIONS MU EP NQF 0038 NUM11 COMBO5 MU NQF0038 NUM11 COMBO5 RS MU NQF0038 DENOM RS MU NQF0038 CHILDREN'S IMMUNIZATIONS MU EP NQF 0038 NUM12 COMBO6 MU NQF0038 NUM12 COMBO6 RS MU NQF0038 DENOM RS MU NQF0038 CHILDREN'S IMMUNIZATIONS MU EP NQF 0038 NUM2 IPV MU NQF0038 NUM2 IPV RS MU NQF0038 DENOM RS MU NQF0038 CHILDREN'S IMMUNIZATIONS MU EP NQF 0038 NUM3 MMR MU NQF0038 NUM3-ALL RS MU NQF0038 DENOM RS MU NQF0038 CHILDREN'S IMMUNIZATIONS MU EP NQF 0038 NUM4 HiB MU NQF0038 NUM4 HIB RS MU NQF0038 DENOM RS MU NQF0038 CHILDREN'S IMMUNIZATIONS MU EP NQF 0038 NUM5 HEP B MU NQF0038 NUM5 RS MU NQF0038 DENOM RS MU NQF0038 CHILDREN'S IMMUNIZATIONS MU EP NQF 0038 NUM6 VZV MU NQF0038 NUM6 VZV RS MU NQF0038 DENOM RS MU NQF0038 CHILDREN'S IMMUNIZATIONS MU EP NQF 0038 NUM7 PCV MU NQF0038 NUM7 PCV RS MU NQF0038 DENOM RS MU NQF0038 CHILDREN'S IMMUNIZATIONS MU EP NQF 0038 NUM8 HEP A MU NQF0038 NUM8 HEP A RS MU NQF0038 DENOM RS MU NQF0038 CHILDREN'S IMMUNIZATIONS MU EP NQF 0038 NUM9 RV MU NQF0038 NUM9 RV RS MU NQF0038 DENOM RS MU NQF0038 CHILDREN'S IMMUNIZATIONS MU EP NQF 0041 MU NQF0041 FLU RS MU NQF0041 FLU DENOM RS MU EP NQF 0059 MU NQF0059 HBA1C NUM RS MU NQF0059 DM DENOM-ALL RS MU EP NQF 0061 MU NQF0061 NUM DM BP<140/90 RS MU NQF0059 DM DENOM-ALL RS MU EP NQF 0064 MU NQF0064 NUM LDL RS MU NQF0059 DM DENOM-ALL RS MU EP NQF 0421 MU NQF0421 BMI NUM ALL RS MU NQF0421 BMI DENOM ALL RS MU NQF0421 ADULT BMI
A brief mention regarding on what you need to report: You need to report the 3 core measures and the 3 additional measures. Only if the denominator of any of the core measures is zero, you need to report any alternate core in addition. If all your 3 cores have denominators of zero, you need to report all 3 alternate cores in addition.
Here is a brief description of the steps we have to do in order to calculate the quality measurements.
- Create the Patient Lists using the Reminders Package
- If there are only rule sets in the above table for a given measure, use these rule sets.
- If there is an extract, you must use the extract.
- Add the patient lists to each of the Quality Measures
- Add the Quality Measures to the Measure Sets
- Update the Outpatient Quality Measures
- Print the Measure Sets
I will illustrate the process with the Core Measures
Create the Patient Lists using the Reminders Package
Getting the Patient Lists
Navigate to the Patient Lists Management Menu from the reminders package:
Select Reminder Managers Menu Option: ? CF Reminder Computed Finding Management ... RM Reminder Definition Management ... SM Reminder Sponsor Management ... TXM Reminder Taxonomy Management ... TRM Reminder Term Management ... LM Reminder Location List Management ... RX Reminder Exchange RT Reminder Test OS Other Supporting Menus ... INFO Reminder Information Only Menu ... DM Reminder Dialog Management ... CP CPRS Reminder Configuration ... RP Reminder Reports ... MST Reminders MST Synchronization Management ... PL Reminder Patient List Menu ... PAR Reminder Parameters ... XM Reminder Extract Menu ... GEC GEC Referral Report Enter ?? for more options, ??? for brief descriptions, ?OPTION for help text. Select Reminder Managers Menu Option: PL Reminder Patient List Menu Select Reminder Patient List Menu Option: ? LRM List Rule Management PLM Patient List Management Enter ?? for more options, ??? for brief descriptions, ?OPTION for help text. Select Reminder Patient List Menu Option: PLM
You will see a screen like this:
Reminder User Patient List Oct 08, 2012@16:31:18 Page: 1 of 2 Available Patient Lists. Item Reminder Patient List Name Created Patients 1 CAD 7/29/05@13:15:55 0 2 DOQIT CAD M1 2006 7/30/05@09:42:55 0 3 DOQIT CAD M7 2005 7/30/05@10:23:48 2 4 DOQIT CAD M8 2005 7/30/05@09:45:37 0 5 DOQIT CAD M9 2005 7/30/05@09:45:46 0 6 DOQIT CAD registerd yyyy nn 7/29/05@17:24:15 2 7 DOQIT DM M7 2005 7/30/05@12:37:41 3 8 DOQIT DM M8 2005 7/30/05@11:51:19 0 9 DOQIT DM PATIENT LIST 10 2005 7/29/05@13:15:57 0 10 DOQIT DM PATIENT LIST 8 2005 7/28/05@11:33:41 0 11 DOQIT DM PATIENT LIST 9 2005 7/28/05@17:26:05 0 12 DOQIT HF M7 2005 7/30/05@11:22:59 3 13 DOQIT HF Mnn yyyy 7/30/05@09:21:48 0 14 DOQIT HF mm2005 PATIENT LIST 7/29/05@13:16 0 15 DOQIT HTN M7 2005 7/30/05@11:32:15 3 16 DOQIT HTN PATIENT LIST 7 2005 7/30/05@09:47:42 0 + + Next Screen - Prev Screen ?? More Actions >>> CO Copy Patient List DE Delete Patient List CV Change View COE Copy to OE/RR Team DCD Display Creation Doc LRM List Rule Management CR Create Patient List DSP Display Patient List QU Quit Select Item: Next Screen// CR
Type CR to Create a Patient List then follow the prompts. Create these 5 lists: The Hypertension Numerator and Denomiator, and the Tobacco Denominator and two Numerators.
Select PATIENT LIST name: MU NQF0013 HTN DENOM2 PL 08/12-10/12 Are you adding 'MU NQF0013 HTN DENOM2 PL 08/12-10/12' as a new REMINDER PATIENT LIST? No// Y (Yes) Secure list?: N// O Purge Patient List after 5 years?: N// O Select LIST RULE SET: MU NQF0013 HTN DENOM2 RS RULE SET Enter Patient List BEGINNING DATE: 8/1/12 (AUG 01, 2012) Enter Patient List ENDING DATE: 10/31/12 (OCT 31, 2012) Include deceased patients on the list? N// O Include test patients on the list? N// O Queue the CREATE PATIENT LIST for MU NQF0013 HTN DENOM2 PL 08/12-10/12: Enter the date and time you want the job to start. It must be after 10/08/2012@16:29:43 Start the task at: N
Select PATIENT LIST name: MU NQF0013 HTN NUMER2 PL 08/12-10/12 Are you adding 'MU NQF0013 HTN NUMER2 PL 08/12-10/12' as a new REMINDER PATIENT LIST? No// Y (Yes) Secure list?: N// O Purge Patient List after 5 years?: N// O Select LIST RULE SET: MU NQF0013 HTN NUMER2 RS RULE SET Enter Patient List BEGINNING DATE: 8/1/12 (AUG 01, 2012) Enter Patient List ENDING DATE: 10/31/12 (OCT 31, 2012) Include deceased patients on the list? N// O Include test patients on the list? N// O Queue the CREATE PATIENT LIST for MU NQF0013 HTN NUMER2 PL 08/12-10/12: Enter the date and time you want the job to start. It must be after 10/08/2012@16:29:43 Start the task at: N
Select PATIENT LIST name: MU NQF0028B TOBACCO INTERV DENOM 8/12-10/12 Are you adding 'MU NQF0028B TOBACCO INTERV DENOM 8/12-10/12' as a new REMINDER PATIENT LIST? No// y (Yes) Secure list?: N// O Purge Patient List after 5 years?: N// O Select LIST RULE SET: MU NQF0028B TOBACCO INTERV DENOM RS RULE SET Enter Patient List BEGINNING DATE: 8/1 (AUG 01, 2012) Enter Patient List ENDING DATE: 10/31 (OCT 31, 2012) Include deceased patients on the list? N// O Include test patients on the list? N// O Queue the CREATE PATIENT LIST for MU NQF0028B TOBACCO INTERV DENOM 8/12-10/12: Enter the date and time you want the job to start. It must be after 10/09/2012@10:10:58 Start the task at:
Select PATIENT LIST name: MU NQF0028A TOBACCO SCREEN NUM 8/12-10/12 Are you adding 'MU NQF0028A TOBACCO SCREEN NUM 8/12-10/12' as a new REMINDER PATIENT LIST? No// Y (Yes) Secure list?: N// O Purge Patient List after 5 years?: N// O Select LIST RULE SET: MU NQF0028A TOBACCO SCREEN NUM RS RULE SET Enter Patient List BEGINNING DATE: 8/1 (AUG 01, 2012) Enter Patient List ENDING DATE: 10/31 (OCT 31, 2012) Include deceased patients on the list? N// O Include test patients on the list? N// O Queue the CREATE PATIENT LIST for MU NQF0028A TOBACCO SCREEN NUM 8/12-10/12: Enter the date and time you want the job to start. It must be after 10/09/2012@10:12:16 Start the task at: N
Select PATIENT LIST name: MU NQF0028B TOBACCO INTERV NUM2 8/12-10/12 Are you adding 'MU NQF0028B TOBACCO INTERV NUM2 8/12-10/12' as a new REMINDER PATIENT LIST? No// Y (Yes) Secure list?: N// O Purge Patient List after 5 years?: N// O Select LIST RULE SET: MU NQF0028B TOBACCO INTERV NUM2 RS RULE SET Enter Patient List BEGINNING DATE: 8/1 (AUG 01, 2012) Enter Patient List ENDING DATE: 10/31 (OCT 31, 2012) Include deceased patients on the list? N// O Include test patients on the list? N// O Queue the CREATE PATIENT LIST for MU NQF0028B TOBACCO INTERV NUM2 8/12-10/12: Enter the date and time you want the job to start. It must be after 10/09/2012@10:14:14 Start the task at: N
The result will look like this. You patient counts will be different. You need to be worried if the denominators are zero; it most probably means that you are not filling out the encounter forms.
19 MU NQF0013 HTN DENOM2 PL 08/12-10/12 10/8/12@16:29:58 1 20 MU NQF0013 HTN NUMER2 PL 08/12-10/12 10/8/12@16:39:14 1 21 MU NQF0028A TOBACCO SCREEN NUM 8/12-10/12 10/9/12@10:12:30 1 22 MU NQF0028B TOBACCO INTERV DENOM 8/12-10/12 10/9/12@10:11:15 2 23 MU NQF0028B TOBACCO INTERV NUM2 8/12-10/12 10/9/12@10:14:28 1
Getting the Extracts
A word to the wise: a lot or all of the measures could have been done as extracts. However, the package was designed around patient lists. The reason extracts were used for two measures is that this was the only way to transport the rule sets.
There are steps here combining extracts from separate months. You can configure the extract to be quarterly or yearly and skip these rather mundane steps; however, you will be only be able to do a specific Quarter or Year.
To get to extracts, type XM from the main Reminders Manager menu. We will use the menu MA for our work; but you can edit the extracts using ED if you wish.
Select Reminder Managers Menu Option: XM Reminder Extract Menu Select Reminder Extract Menu Option: ? MA Reminder Extract Management ED Extract Definition Management EC Extract Counting Rule Management EG Extract Counting Group Management LR List Rule Management Enter ?? for more options, ??? for brief descriptions, ?OPTION for help text.
Type MA
Select Reminder Extract Menu Option: MA Reminder Extract Management Oct 09, 2012@10:16:01 Page: 1 of 1 Available Extract Definitions: Item Extract Type Class 1 MRM-CAD LOCAL 2 MU NQF0038 CHILDREN'S IMMUNIZATIONS LOCAL 3 MU NQF0421 ADULT BMI LOCAL 4 VA-IHD QUERI NATIONAL 5 VA-MH QUERI NATIONAL 6 VA-OEF/OIF MONITOR NATIONAL 7 VOE DOQ-IT CAD EXTRACTION LOCAL 8 VOE DOQ-IT DM EXTRACTION LOCAL 9 VOE DOQ-IT HF EXTRACTION LOCAL 10 VOE DOQ-IT HTN EXTRACTION LOCAL 11 VOE DOQ-IT PC EXTRACTION LOCAL + Next Screen - Prev Screen ?? More Actions EDM Extract Definition Management QU Quit VSE View/Schedule Extract Select Item: Quit// 3 Select Action: (EDM/VSE): VSE//
Type 3 to choose the Extract MU NQF0421 ADULT BMI and enter. Your entry number may be different.
Examine/Schedule Extract Oct 09, 2012@10:16:46 Page: 0 of 0 Extract Name: MU NQF0421 ADULT BMI Next Extract Period: Scheduled to Run: View: Creation Date Order Item Extract Summary Date Created Transmission Date Auto + Next Screen - Prev Screen ?? More Actions CV Change View ME Manual Extract QU Quit ES Extract Summary MT Manual Transmission DE Delete Extract TH Transmission History Select Item: Quit// ME
Type ME. Run an extract for the specific months you are interested in. If you are reporting 3 months for MU Stage 1, you need to do this 3 times.
Select EXTRACT PERIOD (Mnn/yyyy): // M10/2012 WARNING -This period is not complete until 10/31/2012 Are you sure you want to run a MU NQF0421 ADULT BMI extract for M10 2012? N// YES Purge Patient List after 5 years?: N// O Purge Extract Summary after 5 years?: N// O Queue a Reminder Extract MU NQF0421 ADULT BMI for M10/2012 Enter the date and time you want the job to start. It must be after 10/09/2012@10:17:47 Start the task at: N
Select EXTRACT PERIOD (Mnn/yyyy): // M09/2012 Are you sure you want to run a MU NQF0421 ADULT BMI extract for M09 2012? N// YES Purge Patient List after 5 years?: N// O Purge Extract Summary after 5 years?: N// O Queue a Reminder Extract MU NQF0421 ADULT BMI for M09/2012 Enter the date and time you want the job to start. It must be after 10/09/2012@10:22:20 Start the task at: N
Select EXTRACT PERIOD (Mnn/yyyy): // M08/2012 Are you sure you want to run a MU NQF0421 ADULT BMI extract for M08 2012? N// YES Purge Patient List after 5 years?: N// O Purge Extract Summary after 5 years?: N// O Queue a Reminder Extract MU NQF0421 ADULT BMI for M08/2012 Enter the date and time you want the job to start. It must be after 10/09/2012@10:23:13 Start the task at: N
Now go back to the Patient List menu. You will find a large number of lists created by the Extracts.
+Item--Reminder Patient List Name---------------------Created----------Patients- 1 DOQIT CAD registerd yyyy nn 7/29/05@17:24:15 2 PUB F 2 MU NQF0013 HTN DENOM2 PL 08/12-10/12 10/8/12@16:29:58 1 PUB F 3 MU NQF0013 HTN NUMER2 PL 08/12-10/12 10/8/12@16:39:14 1 PUB F 4 MU NQF0028A TOBACCO SCREEN NUM 8/12-10/12 10/9/12@10:12:30 1 PUB F 5 MU NQF0028B TOBACCO INTERV DENOM 8/12-10/12 10/9/12@10:11:15 2 PUB F 6 MU NQF0028B TOBACCO INTERV NUM2 8/12-10/12 10/9/12@10:14:28 1 PUB F 7 MU NQF0421 65Y BMI HIGH NUM1 PL M08/2012 10/9/12@10:23:25 0 PVT F 8 MU NQF0421 65Y BMI HIGH NUM1 PL M09/2012 10/9/12@10:22:38 0 PVT F 9 MU NQF0421 65Y BMI HIGH NUM1 PL M10/2012 10/9/12@10:17:59 0 PVT F 10 MU NQF0421 65Y BMI LOW NUM1 PL M08/2012 10/9/12@10:23:25 0 PVT F 11 MU NQF0421 65Y BMI LOW NUM1 PL M09/2012 10/9/12@10:22:38 0 PVT F 12 MU NQF0421 65Y BMI LOW NUM1 PL M10/2012 10/9/12@10:17:59 0 PVT F 13 MU NQF0421 65Y BMI NL NUM1 PL M08/2012 10/9/12@10:23:25 0 PVT F 14 MU NQF0421 65Y BMI NL NUM1 PL M09/2012 10/9/12@10:22:38 0 PVT F 15 MU NQF0421 65Y BMI NL NUM1 PL M10/2012 10/9/12@10:17:59 0 PVT F 16 MU NQF0421 65Y BMI NUM1-ALL PL M08/2012 10/9/12@10:23:25 0 PVT F 17 MU NQF0421 65Y BMI NUM1-ALL PL M09/2012 10/9/12@10:22:38 0 PVT F 18 MU NQF0421 65Y BMI NUM1-ALL PL M10/2012 10/9/12@10:17:59 0 PVT F 19 MU NQF0421 <65Y BMI HIGH NUM2 PL M08/2012 10/9/12@10:23:25 0 PVT F 20 MU NQF0421 <65Y BMI HIGH NUM2 PL M09/2012 10/9/12@10:22:38 0 PVT F 21 MU NQF0421 <65Y BMI HIGH NUM2 PL M10/2012 10/9/12@10:18 1 PVT F 22 MU NQF0421 <65Y BMI LOW NUM2 PL M08/2012 10/9/12@10:23:25 0 PVT F 23 MU NQF0421 <65Y BMI LOW NUM2 PL M09/2012 10/9/12@10:22:38 0 PVT F 24 MU NQF0421 <65Y BMI LOW NUM2 PL M10/2012 10/9/12@10:18 0 PVT F 25 MU NQF0421 <65Y BMI NL NUM2 PL M08/2012 10/9/12@10:23:26 0 PVT F 26 MU NQF0421 <65Y BMI NL NUM2 PL M09/2012 10/9/12@10:22:38 0 PVT F 27 MU NQF0421 <65Y BMI NL NUM2 PL M10/2012 10/9/12@10:18 1 PVT F 28 MU NQF0421 <65Y BMI NUM2-ALL PL M08/2012 10/9/12@10:23:26 0 PVT F 29 MU NQF0421 <65Y BMI NUM2-ALL PL M09/2012 10/9/12@10:22:38 0 PVT F 30 MU NQF0421 <65Y BMI NUM2-ALL PL M10/2012 10/9/12@10:18 2 PVT F 31 MU NQF0421 BMI DENOM ALL PL M08/2012 10/9/12@10:23:26 0 PVT F 32 MU NQF0421 BMI DENOM ALL PL M09/2012 10/9/12@10:22:38 0 PVT F 33 MU NQF0421 BMI DENOM ALL PL M10/2012 10/9/12@10:18 2 PVT F 34 MU NQF0421 BMI DENOM1 PL M08/2012 10/9/12@10:23:26 0 PVT F 35 MU NQF0421 BMI DENOM1 PL M09/2012 10/9/12@10:22:38 0 PVT F 36 MU NQF0421 BMI DENOM1 PL M10/2012 10/9/12@10:18 0 PVT F 37 MU NQF0421 BMI DENOM2 PL M08/2012 10/9/12@10:23:26 0 PVT F 38 MU NQF0421 BMI DENOM2 PL M09/2012 10/9/12@10:22:38 0 PVT F 39 MU NQF0421 BMI DENOM2 PL M10/2012 10/9/12@10:18 2 PVT F 40 MU NQF0421 BMI NUM ALL PL M08/2012 10/9/12@10:23:26 0 PVT F 41 MU NQF0421 BMI NUM ALL PL M09/2012 10/9/12@10:22:38 0 PVT F 42 MU NQF0421 BMI NUM ALL PL M10/2012 10/9/12@10:18 2 PVT F
Now, combine the Numerators and Denominators for the Reporting Period:
Combine these:
31 MU NQF0421 BMI DENOM ALL PL M08/2012 10/9/12@10:23:26 0 PVT F 32 MU NQF0421 BMI DENOM ALL PL M09/2012 10/9/12@10:22:38 0 PVT F 33 MU NQF0421 BMI DENOM ALL PL M10/2012 10/9/12@10:18 2 PVT F
and these
40 MU NQF0421 BMI NUM ALL PL M08/2012 10/9/12@10:23:26 0 PVT F 41 MU NQF0421 BMI NUM ALL PL M09/2012 10/9/12@10:22:38 0 PVT F 42 MU NQF0421 BMI NUM ALL PL M10/2012 10/9/12@10:18 2 PVT F
You combine them by going into the Rules Menu, choosing CV to change view, then going into the Patient List Rule view. In there, you will create 6 patient list rules, one for each of the months. Then you CV back to Rule Set view, and add two rule sets, one combining the 3 denominator Patient List Rules, and one combining the 3 numerator Patient List Rules. Last, in the Patient Lists menu create the Patient Lists from these two rules sets for the final numerator and denominator. Following is the transcipt of this operation:
>> Go into the Rules menu first (PL > LRM from the main Reminders Manager menu), then type "CV".
Select one of the following: F Finding Rule P Patient List Rule R Reminder Rule S Rule Set TYPE OF VIEW: F// P
You will see this:
List Rule Management Oct 09, 2012@10:31:17 Page: 1 of 3 Item Patient List Rule Name Class 1 MU NQF0038 NUM1 DPT PR LOCAL 2 MU NQF0038 NUM2 IPV PR LOCAL 3 MU NQF0038 NUM3-1 PR LOCAL 4 MU NQF0038 NUM3-2 PR LOCAL 5 MU NQF0038 NUM3-3 PR LOCAL 6 MU NQF0038 NUM3-4 PR LOCAL 7 MU NQF0038 NUM3-ALL PR LOCAL 8 MU NQF0038 NUM5 HEP B PR LOCAL 9 MU NQF0038 NUM6 VZV PR LOCAL 10 MU NQF0038 NUM7 PCV PR LOCAL 11 MU NQF0421 65Y BMI HIGH NUM1 PLL LOCAL 12 MU NQF0421 65Y BMI LOW NUM1 PLL LOCAL 13 MU NQF0421 65Y BMI NL NUM1 PLL LOCAL + + Next Screen - Prev Screen ?? More Actions CV Change View TEST (Test Rule Set) CR Create Rule QU Quit DR Display/Edit Rule Select Item: Next Screen// CR
Type CR to create patient list rules. You will do this 6 times.
NAME: MU NQF0421 BMI DENOM ALL PL M08/2012 PR Replace SHORT DESCRIPTION: CLASS: L LOCAL USE EXISTING PT LIST: MU NQF0421 BMI DENOM ALL PL M08/2012 Input your edit comments. Edit? NO//
NAME: MU NQF0421 BMI DENOM ALL PL M09/2012 PR Replace SHORT DESCRIPTION: CLASS: L LOCAL USE EXISTING PT LIST: MU NQF0421 BMI DENOM ALL PL M09/2012 Input your edit comments. Edit? NO//
NAME: MU NQF0421 BMI DENOM ALL PL M10/2012 PR Replace SHORT DESCRIPTION: CLASS: L LOCAL USE EXISTING PT LIST: MU NQF0421 BMI DENOM ALL PL M10/2012 Input your edit comments. Edit? NO//
NAME: MU NQF0421 BMI NUM ALL PL M08/2012 PR Replace SHORT DESCRIPTION: CLASS: L LOCAL USE EXISTING PT LIST: MU NQF0421 BMI NUM ALL PL M08/2012 Input your edit comments. Edit? NO//
NAME: MU NQF0421 BMI NUM ALL PL M09/2012 PR Replace SHORT DESCRIPTION: CLASS: L LOCAL USE EXISTING PT LIST: MU NQF0421 BMI NUM ALL PL M09/2012 Input your edit comments. Edit? NO//
NAME: MU NQF0421 BMI NUM ALL PL M10/2012 PR Replace SHORT DESCRIPTION: CLASS: L LOCAL USE EXISTING PT LIST: MU NQF0421 BMI NUM ALL PL M10/2012 Input your edit comments. Edit? NO//
Now you will change back to the Rule Set view.
Select one of the following: F Finding Rule P Patient List Rule R Reminder Rule S Rule Set TYPE OF VIEW: F// S
Now, combine the Patient List Rules in a rule set.
Numerators:
NAME: MU NQF0421 BMI NUM ALL 8/12-10/12 RS Replace SHORT DESCRIPTION: CLASS: L LOCAL Select SEQUENCE: 10 Are you adding '10' as a new SEQUENCE (the 1ST for this REMINDER LIST RULE)? No// Y (Yes) SEQUENCE LIST RULE: MU NQF0421 BMI NUM ALL PL M08/2012 PR PATIENT LIST LIST RULE: MU NQF0421 BMI NUM ALL PL M08/2012 PR // OPERATION: A ADD PATIENT SEQUENCE BEGINNING DATE/TIME: SEQUENCE ENDING DATE/TIME: Select SEQUENCE: 20 Are you adding '20' as a new SEQUENCE (the 2ND for this REMINDER LIST RULE)? No// Y (Yes) SEQUENCE LIST RULE: MU NQF0421 BMI NUM ALL PL M09/2012 PR PATIENT LIST LIST RULE: MU NQF0421 BMI NUM ALL PL M09/2012 PR // OPERATION: A ADD PATIENT SEQUENCE BEGINNING DATE/TIME: SEQUENCE ENDING DATE/TIME: Select SEQUENCE: 30 Are you adding '30' as a new SEQUENCE (the 3RD for this REMINDER LIST RULE)? No// Y (Yes) SEQUENCE LIST RULE: MU NQF0421 BMI NUM ALL PL M10/2012 PR PATIENT LIST LIST RULE: MU NQF0421 BMI NUM ALL PL M10/2012 PR // OPERATION: A ADD PATIENT SEQUENCE BEGINNING DATE/TIME: SEQUENCE ENDING DATE/TIME: Select SEQUENCE: Input your edit comments. Edit? NO//
Denominators:
NAME: MU NQF0421 BMI DEN ALL 8/12-10/12 RS Replace SHORT DESCRIPTION: CLASS: L LOCAL Select SEQUENCE: 10 Are you adding '10' as a new SEQUENCE (the 1ST for this REMINDER LIST RULE)? No// Y (Yes) SEQUENCE LIST RULE: MU NQF0421 BMI DENOM ALL PL M08/2012 PR PATIENT LIST LIST RULE: MU NQF0421 BMI DENOM ALL PL M08/2012 PR // OPERATION: A ADD PATIENT SEQUENCE BEGINNING DATE/TIME: SEQUENCE ENDING DATE/TIME: Select SEQUENCE: 20 Are you adding '20' as a new SEQUENCE (the 2ND for this REMINDER LIST RULE)? No// Y (Yes) SEQUENCE LIST RULE: MU NQF0421 BMI DENOM ALL PL M09/2012 PR PATIENT LIST LIST RULE: MU NQF0421 BMI DENOM ALL PL M09/2012 PR // OPERATION: A ADD PATIENT SEQUENCE BEGINNING DATE/TIME: SEQUENCE ENDING DATE/TIME: Select SEQUENCE: 30 Are you adding '30' as a new SEQUENCE (the 3RD for this REMINDER LIST RULE)? No// Y (Yes) SEQUENCE LIST RULE: MU NQF0421 BMI DENOM ALL PL M10/2012 PR PATIENT LIST LIST RULE: MU NQF0421 BMI DENOM ALL PL M10/2012 PR // OPERATION: A ADD PATIENT SEQUENCE BEGINNING DATE/TIME: SEQUENCE ENDING DATE/TIME: Select SEQUENCE: Input your edit comments. Edit? NO//
Now go to Patient List Management option, and then create the combined lists (PL > PLM on the menu system; then type CR)
Numerator:
Select PATIENT LIST name: MU NQF0421 BMI NUM ALL PL 8/12-10/12 Are you adding 'MU NQF0421 BMI NUM ALL PL 8/12-10/12' as a new REMINDER PATIENT LIST? No// Y (Yes) Secure list?: N// O Purge Patient List after 5 years?: N// O Select LIST RULE SET: MU,NQF0421,RS 1 MU NQF0421 65Y BMI HIGH NUM1 RS RULE SET 2 MU NQF0421 65Y BMI LOW NUM1 RS RULE SET 3 MU NQF0421 65Y BMI NL NUM1 RS RULE SET 4 MU NQF0421 65Y BMI NUM1-ALL RS RULE SET 5 MU NQF0421 <65Y BMI HIGH NUM2 RS RULE SET Press <Enter> to see more, '^' to exit this list, OR CHOOSE 1-5: 6 MU NQF0421 <65Y BMI LOW NUM2 RS RULE SET 7 MU NQF0421 <65Y BMI NL NUM2 RS RULE SET 8 MU NQF0421 <65Y BMI NUM2-ALL RS RULE SET 9 MU NQF0421 BMI DEN ALL 8/12-10/12 RS RULE SET 10 MU NQF0421 BMI DENOM ALL RS RULE SET Press <Enter> to see more, '^' to exit this list, OR CHOOSE 1-10: 9 MU NQF0421 BMI DEN ALL 8/12-10/12 RS RULE SET Enter Patient List BEGINNING DATE: This is a required response. Enter '^' to exit Enter Patient List BEGINNING DATE: 8/1/12 (AUG 01, 2012) Enter Patient List ENDING DATE: 10/31/12 (OCT 31, 2012) Include deceased patients on the list? N// O Include test patients on the list? N// O Queue the CREATE PATIENT LIST for MU NQF0421 BMI NUM ALL PL 8/12-10/12: Enter the date and time you want the job to start. It must be after 10/09/2012@10:47:23 Start the task at: N
Denominator
Select PATIENT LIST name: MU NQF0421 BMI DENOM ALL PL 8/12-10/12 Are you adding 'MU NQF0421 BMI DENOM ALL PL 8/12-10/12' as a new REMINDER PATIENT LIST? No// Y (Yes) Secure list?: N// O Purge Patient List after 5 years?: N// O Select LIST RULE SET: MU,NQF0421,DEN,RS 1 MU NQF0421 BMI DEN ALL 8/12-10/12 RS RULE SET 2 MU NQF0421 BMI DENOM ALL RS RULE SET 3 MU NQF0421 BMI DENOM1 RS RULE SET 4 MU NQF0421 BMI DENOM2 RS RULE SET CHOOSE 1-4: 1 MU NQF0421 BMI DEN ALL 8/12-10/12 RS RULE SET Enter Patient List BEGINNING DATE: 8/1 (AUG 01, 2012) Enter Patient List ENDING DATE: 10/31 (OCT 31, 2012) Include deceased patients on the list? N// O Include test patients on the list? N// O Queue the CREATE PATIENT LIST for MU NQF0421 BMI DENOM ALL PL 8/12-10/12: Enter the date and time you want the job to start. It must be after 10/09/2012@10:49:28 Start the task at: N
After this, you should then see two lines like these somewhere in the Patient lists (NB: these lines are not adjacent)
31 MU NQF0421 BMI DENOM ALL PL 8/12-10/12 10/9/12@10:49:42 2 41 MU NQF0421 BMI NUM ALL PL 8/12-10/12 10/9/12@10:47:43 2
In the end, you may want to copy the list names into a document to copy and paste them into Quality Measures package.
MU NQF0013 HTN DENOM2 PL 08/12-10/12 10/8/12@16:29:58 1 PUB F MU NQF0013 HTN NUMER2 PL 08/12-10/12 10/8/12@16:39:14 1 PUB F MU NQF0028A TOBACCO SCREEN NUM 8/12-10/12 10/9/12@10:12:30 1 PUB F MU NQF0028B TOBACCO INTERV DENOM 8/12-10/12 10/9/12@10:11:15 2 PUB F MU NQF0028B TOBACCO INTERV NUM2 8/12-10/12 10/9/12@10:14:28 1 PUB F MU NQF0421 BMI DENOM ALL PL 8/12-10/12 10/9/12@10:49:42 2 MU NQF0421 BMI NUM ALL PL 8/12-10/12 10/9/12@10:47:43 2
Create the Patient Lists using the Reminders Package
Inpatient Set-up
- 1. Set-up Parameters
- Log into VistA (user must have access to C0Q package). From GTM prompt:
GTM>D ^XUP -- enter the programmer environment Select OPTION NAME: COQ Q -- enter C0Q module 1 C0Q QUALITY MEASURE DEFINITION QUALITY MEASURE DEFINITION 2 C0Q QUALITY MEASUREMENT MENU QUALITY MEASUREMENT MENU CHOOSE 1-2: 2 C0Q QUALITY MEASUREMENT MENU QUALITY MEASUREMENT MENU Select QUALITY MEASUREMENT MENU Option: SETUP QUALITY REPORTING -- menu for C0Q set-up DISPLAY QUALITY MEASURES EDIT SUPERUSERS EP EDIT PARMS INP EDIT PARMS MEASURE SET EDIT MU MEASURE EDIT QUALITY MEASURE EDIT Select SETUP QUALITY REPORTING Option: EP EDIT PARMS
- Prior to building quality measures and quality measure sets, we must establish the parameters. If you’re building outpatient quality
- measures, “EP EDIT PARMS” should be selected (as seen above). If you’re building, inpatient quality measures, “INP EDIT PARMS” should be
- selected.
Select C0Q PARAMETER NAME: MU2012 Quality Measures -- Enter Name of Parameter Are you adding 'MU2012 Quality Measures' as a new C0Q PARAMETER (the 1ST)? No// y (Yes) NAME: MU2012 Quality Measures Replace MEASUREMENT PERIOD KEY: MU12 -- Period Key groups measures and lists so easy to locate and search PARAMETER TYPE: OUTPATIENT -- defines criteria for MU Measure data EP MU MEASUREMENT SET: -- To be left empty. We are building Quality Measures NOT MU measures. EP QUALITY MEASUREMENT SET: -- To be left empty for now. We will come back to add quality measure set. Select CLINIC: --Clinic NOT required for quality measure build. The clinic (if applicable) should be built into the reminder/patient list build PATIENT LIST LABEL: Select SUBSCRIBER: - SUBCRIBER field designates who is allowed to see the specific quality measure set.
- End of Quality Measure Parameter Set-up. [Enter] out of the menu until you reach the QUALITY MEASUREMENT MENU (C0Q Q menu as seen below):
COPY OVER PATIENT LISTS ED-1 COMPUTATION ED-2 COMPUTATION EP UPDATE MU MEASURES INP UPDATE MU MEASURES PQRI MENU ... PQRI PRINT XML PRINT C0Q MEASURES SETUP QUALITY REPORTING ... Select SETUP QUALITY REPORTING Option:
- 2. Create Quality Measures
GTM>D ^XUP -- enter the programmer environment Select OPTION NAME: COQ Q -- enter C0Q module 1 C0Q QUALITY MEASURE DEFINITION QUALITY MEASURE DEFINITION 2 C0Q QUALITY MEASUREMENT MENU QUALITY MEASUREMENT MENU CHOOSE 1-2: 2 C0Q QUALITY MEASUREMENT MENU QUALITY MEASUREMENT MENU COPY OVER PATIENT LISTS ED-1 COMPUTATION ED-2 COMPUTATION EP UPDATE MU MEASURES INP UPDATE MU MEASURES PQRI MENU ... PQRI PRINT XML PRINT C0Q MEASURES SETUP QUALITY REPORTING ... Select QUALITY MEASUREMENT MENU Option: SETUP QUALITY REPORTING DISPLAY QUALITY MEASURES EDIT SUPERUSERS EP EDIT PARMS INP EDIT PARMS MEASURE SET EDIT MU MEASURE EDIT QUALITY MEASURE EDIT Select SETUP QUALITY REPORTING Option: QUALITY MEASURE EDIT Select C0Q QUALITY MEASURE NAME: MU EP NQF 0024 -- Name of my quality measure. NAME: MU EP NQF 0024// MU YEAR KEY: TITLE: NQF0024 Weight Assessment and Counseling for Children and Adolescents Replace -- Title of my quality measure VERY LONG DESCRIPTION: -- Description of my quality measure 1>Percentage of patients 2 -17 years of age 2>who had an outpatient visit with a Primary Care Physician 3>(PCP) or OB/GYN and who had evidence of BMI 4>percentile documentation, counseling for nutrition and 5>counseling for physical activity during the measurement 6>year. EDIT Option: DISPLAY NAME: NQF0024 Weight Assessment and Counseling for Children and Adolescents Replace REPORTING NAME: NQF0027// NUMERATOR PATIENT LIST: MU NQF0024 -- Reminder Patient List (numerator) for this quality measures should be added. 1 MU NQF0024 OBESITY KIDS DENOM PL 2 MU NQF0024 OBESITY KIDS NUM PL CHOOSE 1-2: 2 MU NQF0024 OBESITY KIDS NUM PL -- Reminder Patient List (denominator) for this quality measure should be added. DENOMINATOR PATIENT LIST: MU NQF0024 1 MU NQF0024 OBESITY KIDS DENOM PL 2 MU NQF0024 OBESITY KIDS NUM PL CHOOSE 1-2: 1 MU NQF0024 OBESITY KIDS DENOM PL QRDA TEMPLATE ROOT: QRDA CODE: :
- In this step we are creating a Quality Measure and linking the proper numerator and denominator patient lists (from the reminders package)
- to the quality measure. These patient lists identify our population and our percentages are calculated based on list data. When installed,
- the C0Q package will likely have several Meaningful Use Quality Measures and patient lists available. If you are unable to find an applicable
- patient list, we recommend you look for an existing list, shared on the WV trac server. From the WV trac server you can download and import
- the .prd files (import into the reminders package), saving you hours of work. Please reference the reminders package for import instructions.
- https://trac.opensourcevista.net/browser/quality/tags/mu/PRD
- In addition, from year to year some quality measures may use the same numerator and dominator lists. If this applies to you, you can simply
- re-use (refresh) and rename a measure instead of building a new measure from scratch. Also, in this example we only created one quality
- measure to be included in our quality measure set. If you would like multiple measures to be included, you would create additional measures
- and name accordingly. Please note: Consistent naming is crucial for keeping measures organized.
- 3. Create Quality Measure SET and add Quality Measure(s)
GTM>D ^XUP -- enter the programmer environment Select OPTION NAME: COQ Q -- enter C0Q module 1 C0Q QUALITY MEASURE DEFINITION QUALITY MEASURE DEFINITION 2 C0Q QUALITY MEASUREMENT MENU QUALITY MEASUREMENT MENU CHOOSE 1-2: 2 C0Q QUALITY MEASUREMENT MENU QUALITY MEASUREMENT MENU COPY OVER PATIENT LISTS ED-1 COMPUTATION ED-2 COMPUTATION EP UPDATE MU MEASURES INP UPDATE MU MEASURES PQRI MENU ... PQRI PRINT XML PRINT C0Q MEASURES SETUP QUALITY REPORTING ... Select QUALITY MEASUREMENT MENU Option: SETUP QUALITY REPORTING DISPLAY QUALITY MEASURES EDIT SUPERUSERS EP EDIT PARMS INP EDIT PARMS MEASURE SET EDIT MU MEASURE EDIT QUALITY MEASURE EDIT Select SETUP QUALITY REPORTING Option: MEASURE SET EDIT Select C0Q MEASUREMENTS SET NAME: MU12 Quality Measure Set -- Name of my measure set Are you adding 'MU12 Quality Measure Set' as a new C0Q MEASUREMENTS (the 12TH)? No// y (Yes) SET NAME: MU12 Quality Measure Set Replace BEGIN DATE: --Begin Date is NOT required for quality measure build. The date (if applicable) should be built into the reminder build. END DATE: --End Date is NOT required for quality measure build. The date (if applicable) should be built into the reminder build. LOCKED: -- Measure Set LOCK should be set after reporting period has ended. MU YEAR KEY: MU12 Select MEASURE: MU EP NQF 0024 -- Adding our quality measure (created in step 2) to our measure set Select MEASURE: MU EP NQF 0024 NQF0024 Weight Assessment and Counseling for Children and Adolescents Are you adding 'MU EP NQF 0024' as a new MEASURE (the 1ST for this C0Q MEASUREMENTS)? No// y (Yes) NUMERATOR FILTER LIST: DENOMINATOR FILTER LIST: Select MEASURE: Select C0Q MEASUREMENTS SET NAME:
- All applicable Quality Measures created in Step 2 should be added to your Measure Set.
- 4. Link Measure Set to Parameter
GTM>D ^XUP -- enter the programmer environment Select OPTION NAME: COQ Q -- enter C0Q module 1 C0Q QUALITY MEASURE DEFINITION QUALITY MEASURE DEFINITION 2 C0Q QUALITY MEASUREMENT MENU QUALITY MEASUREMENT MENU CHOOSE 1-2: 2 C0Q QUALITY MEASUREMENT MENU QUALITY MEASUREMENT MENU COPY OVER PATIENT LISTS ED-1 COMPUTATION ED-2 COMPUTATION EP UPDATE MU MEASURES INP UPDATE MU MEASURES PQRI MENU ... PQRI PRINT XML PRINT C0Q MEASURES SETUP QUALITY REPORTING ... Select QUALITY MEASUREMENT MENU Option: SET-UP QUALITY REPORTING DISPLAY QUALITY MEASURES EDIT SUPERUSERS EP EDIT PARMS INP EDIT PARMS MEASURE SET EDIT MU MEASURE EDIT QUALITY MEASURE EDIT Select SETUP QUALITY REPORTING Option: EP EDIT PARMS -- or INP EDIT PARMS depending on INP or OP Select C0Q PARAMETER NAME: MU2012 Quality Measures -- Parameter created in Step 1 NAME: MU2012 Quality Measures Replace -- Hit Enter to accept the default answer MEASUREMENT PERIOD KEY: MU12// -- Hit Enter to accept the default answer PARAMETER TYPE: OUTPATIENT// -- Hit Enter to accept the default answer EP MU MEASUREMENT SET: -- Leave blank, we are not creating a MU measure set EP QUALITY MEASUREMENT SET: MU12 Quality Measure Set -- Add Quality Measure Set created in Step 3 Select CLINIC: -- Hit Enter to accept the default answer PATIENT LIST LABEL: -- Hit Enter to accept the default answer Select SUBSCRIBER: -- Hit Enter to accept the default answer Select C0Q PARAMETER NAME:
- Your Quality Measure Set is now linked to your parameter. ** QUALITY MEASURE BUILD IS COMPLETE**
- 5. Copy Over Patient Lists
- Prior to printing or displaying Quality Measure data, a copy of the patient list (that are being used in your quality measure set) data is
needed. To update:
GTM>D ^XUP -- enter the programmer environment Select OPTION NAME: COQ Q -- enter C0Q module 1 C0Q QUALITY MEASURE DEFINITION QUALITY MEASURE DEFINITION 2 C0Q QUALITY MEASUREMENT MENU QUALITY MEASUREMENT MENU CHOOSE 1-2: 2 C0Q QUALITY MEASUREMENT MENU QUALITY MEASUREMENT MENU COPY OVER PATIENT LISTS ED-1 COMPUTATION ED-2 COMPUTATION EP UPDATE MU MEASURES INP UPDATE MU MEASURES PQRI MENU ... PQRI PRINT XML PRINT C0Q MEASURES SETUP QUALITY REPORTING ... Select QUALITY MEASUREMENT MENU Option: COPY OVER PATIENT LISTS Select C0Q MEASUREMENTS SET NAME: MU12 Quality Measure Set C0QFDA(1130580001.2011,"1,12,",1.1)=2 C0QFDA(1130580001.20111,"+1,1,12,",.01)=13 C0QFDA(1130580001.20111,"+2,1,12,",.01)=14 C0QFDA(1130580001.2011,"1,12,",2.1)=13 C0QFDA(1130580001.20112,"+1,1,12,",.01)=12 C0QFDA(1130580001.20112,"+10,1,12,",.01)=90 C0QFDA(1130580001.20112,"+11,1,12,",.01)=91………….
- This will ensure we are printing or displaying the most up to date data in the system.
- 6. Print C0Q Measures
GTM>D ^XUP -- enter the programmer environment Select OPTION NAME: COQ Q -- enter C0Q module 1 C0Q QUALITY MEASURE DEFINITION QUALITY MEASURE DEFINITION 2 C0Q QUALITY MEASUREMENT MENU QUALITY MEASUREMENT MENU CHOOSE 1-2: 2 C0Q QUALITY MEASUREMENT MENU QUALITY MEASUREMENT MENU COPY OVER PATIENT LISTS ED-1 COMPUTATION ED-2 COMPUTATION EP UPDATE MU MEASURES INP UPDATE MU MEASURES PQRI MENU ... PQRI PRINT XML PRINT C0Q MEASURES SETUP QUALITY REPORTING ... Select QUALITY MEASUREMENT MENU Option: Print C0Q MEASURES Select C0Q MEASUREMENTS SET NAME: MU12 Quality Measure Set DEVICE: TELNET C0Q MEASUREMENTS LIST APR 4,2012 07:50 PAGE 1 MEASURE:DISPLAY NAME DENOMINATOR NUMERATOR PERCENTAGE -------------------------------------------------------------------------------- NQF0024 Weight 13 2 15.00 Assessment and Counseling for Children and Adolescents
Contributors
- - George Lilly
- - Oroville Hosptial
- - Ryan Grimm and Luke Dubay (Install and Config documentation)
- -Twin Cities EMR Consulting, LLC. (Minneapolis, MN)