1. e-MDs East Central User Training Webinar
October 25, 2012
1:00 pm ET
Operator: Good afternoon, ladies and gentlemen, and thank you for waiting.
Welcome to the e-MDs East Central User Training Webinar. All lines have
been placed on listen-only mode, and the floor will be opened for your
questions and comments periodically throughout the presentation. If you
would like to utilize the Chat function, please enter your questions
throughout the presentation. We will try to get through as many as we
can.
Without further ado, it is my pleasure to turn the floor over to your host,
Ms. Fran Otte. Ms. Otte, the floor is yours.
Fran Otte: Thank you. Hello and welcome. My name is Fran Otte, and I am the
Senior Quality Improvement Facilitator at Telegen, the Iowa QIO. There
are 23 Quality Improvement Organizations funded by CMS who are
hosting this program today, and we will be joined by Robin Bowles from
e-MDs to provide us with this hour of training.
For those of you who are not familiar with the QIOs, every three years,
CMS implements a cycle of work known as the Scope of Work, and this is
our tenth one. So Quality Improvement Organizations are charged with
assisting the healthcare community improve the safety, effectiveness, and
efficiency of patient care. These no-cost consulting services help to meet
CMS's goal for better health for individuals, better health for populations
and communities, and affordable care through improvement. We are
working with your communities, addressing immunizations, cancer
screenings, as well as the cardiovascular health.
We assist with better understanding and utilization of your electronic
health record, and particularly capturing data and reporting that will lead
to better population health. If you would like more information on the
current initiatives of your state's QIO, you can utilize the Chat button, and
I will forward their contact information to you.
I want to thank e-MDs for their commitment and assistance to help the
QIOs and practices by providing these free user training opportunities.
1

2. Now, one more thing I wanted to talk about is 2012 PQRS data
submission. We have two months left to boost data in your clinics and
capture the 80% of the patients who meet each measure. You may want
to start running reports now to see how you are looking on at least three
of those measures. You can then address any deficits and follow up with
patients in order to better provide patient care and better population
management and be successful PQRS submitters.
If you don't already have an IACs account, you will want to get started on
that right away, as it takes several weeks for approval. Work with the
QIO and the QualityNet help desk. And remember, you have until
February 28, 2013, to submit your 2012 PQRS data through your
electronic health record.
And with that, I would like to now turn the rest of the webinar over to
Robin Bowles, who will educate us on e-MDs reports and so much more.
Thank you, Robin.
Robin Bowles: Thank you. Good afternoon, everyone. I've got a whole bunch of
questions, so we're just going to start right at the top. I received a
question about Measure Number 237, so we're going to go ahead and
look at the dashboard. Now, the thing I want to remind everybody
about, and I recognize that you all need the 2012 dashboard. It's due to
be released either late next week or the very beginning of the following
week. I was hoping to have one today to show you, but that was not
possible. So just know that that's coming. And when you're running a
PQRS dashboard, it is the 2011. Most of the measures, or the criteria for
the measures, haven't changed, but there are some measures that won't
be on there, and you just have to look to see.
So we're going to take a look at Measure Number 237 and see what kind
of data has been generated. And we'll start at the beginning of the year
and go to today's date. And I'm going to run this for--we'll just go ahead
and run it for one provider. It's going to take its time. And then we'll see
if 237 was--yes, that was a last year's measure as well. So we're going
to go look and see what we've got.
We have three eligible for the denominator and none meeting numerator.
So in order to deal with this, I need to go and see who should have met
the measure, but they didn't. Carrie Coughlin should have met the
measure, but she didn't, and apparently she's been here several times.
This particular measure requires two visits to even be in the denominator,
but apparently we're not taking blood pressure during those visits.
So if I want to go back and look to see, "Why am I not doing that?" I can
actually pull up her chart and see, "Are we forgetting to put them in the
note?" Because it does require, you can't just take the vitals up here in
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3. the vitals module. They do have to be brought into the note, because the
query is in the Vitals Flow Sheet.
So looking at her visits, no vitals. I suspect they're all like that, because
she's kind of one of my favorites that I use. Here's another one, no
vitals. So that's why she's not meeting the measure.
To correctly, to get a patient to meet the measure, they have to have two
visits within the period. And what I want to show you guys now is the
Education Department's been working furiously on documents to help you
guys with this, so I'm going to go ahead and show you some of the ones
that we've already got ready. And they'll actually be out, they're working
on the PQRS Resource Center now. So I'm hoping that maybe it will be
up the very, very first of next week, maybe even by tomorrow. But let
me go ahead and show you what they look like.
So it's going to take you through the logic required for the denominator,
and it will tell you the definition of the population that it's trying to query
for. It's going to tell you that all the patients on this report should be 18
years of age or older, and they have to have a documented diagnosis of
hypertension at any time before or during the measurement period. So
as long as they have an active diagnosis of hypertension in their current
problems, they should qualify for that portion of the patient population.
But to actually be in the denominator, they have to meet the initial
criteria, so they've got to have hypertension in their current problem, and
they need to be at least 18 years of age. The additional criteria that puts
them in the denominator is that they have two face-to-face visits with the
eligible professional during the measurement period. And these are the
codes that will qualify them for that. And then it gives you the list of
codes for hypertension.
To be in the numerator, they've got to have documentation of their
systolic and diastolic blood pressure. There are no exclusions for this
report.
And then there's a section at the end of each KB article that tells you how
to meet the measure using e-MDs. So it's going to take you through
some workflows.
This one talks about recording the blood pressure in the vitals module
and then adding it to the visit note. You can also add the vitals directly
to the visit note. So some people, because of their workflow, the layout
of their clinic, will take the vitals outside of the note and bring them into
the note. Others will just go ahead and start the note and put the vitals
in there. So either way, as long as those vitals are brought into the visit
note, your patient will be fine.
3

4. Let's see here. The vitals do not populate that Vitals Flow Sheet until
they are brought into the note. So blood pressures taken outside of a
note are not going to qualify. I just thought that was important and that
that was something that you guys might need to know. So that's what
these KB articles are going to look like and how they're going to work.
So that was the first question that I had. And hopefully, that's going to
answer the question.
Another really interesting question that I got had to do with whether or
not the PQRS measures can be satisfied if we have a rule running that's
kind of helping us with our PQRS. Can that rule be satisfied with flow
sheet content? And yes, it absolutely can.
So I want to show you guys some of the things that I've done. In my
Rule Manager, what I did was I took my mammogram rule, which is right
here, and I added that rule. And there was a new box that was added
back in 70, I think, and it says, "Use the result to satisfy the rule." So in
other words, the rules typically, or at least in the past, they could only be
satisfied by an order. We now have the ability to satisfy that rule by a
result. So I checked this box, and then I indicated what the test codes
are that satisfy that rule, and then in my flow sheet, in my Preventive
Care Flow Sheet, I have linked my mammogram field data element to the
77057, which is the preventive mammogram code. And it's the code that
my clinic uses. If you're not ordering it, it doesn't really matter what you
link it to as long as it's one of the codes that satisfy that PQRS measure.
So let me give you a scenario. If I am a specialist--or no, let's see. I'm a
primary care doctor, and I have patients that I don't order their
mammograms because their OB-GYN does that. They do their annual
exam, and they order their mammograms. However, I always get a copy
of that result.
So the workflow would be, if I can set my rule up like this and then I put
in my Preventive Care Flow Sheet, I put that mammogram field and link it
up to that 77057, that rule is going to be satisfied by that mammogram
documentation. And I'll show you what I mean.
So once you've done that, and you're running your rule like that, if you
have a patient, and I actually do, I was checking one earlier to see if I
had this scenario already set up, and I did. I think it was this patient
right here. No, it was Carrie Coughlin.
So if I look in her rules, the mammogram rule is not there for her. So it's
been satisfied, and it's not in her pending. And so she meets all the
criteria, so why isn't she in here? The reason is because in my Preventive
Care Flow Sheet, right here, she had a current mammogram result. And
that's the reason why her rule isn't showing, because her rule has been
satisfied by this result in this field.
4

5. The other document that you're going to be seeing out on the Support
Center very quickly that's going to help you with this--I'm actually going
to go through some of those workflows today, but I want you to see it.
It's called the PQRS Numerator Methodology Document. And what it's
going to do is it's going to show you, step-by-step, click-by-click
instructions with screen shots, all of the ways that you can satisfy a
numerator.
For instance, if I want to know, "How can I satisfy it by ordering a CPT in
a visit note? How can I attach a CPT to a template item so it's captured
in the visit note?" "What do they mean when they say adding a
medication or an active medication? What does that mean?" That's
adding or prescribing or refilling a medication, and this is how that work
flows. An immunization order, documentation of an immunization in a
flow sheet.
The one that most people don't know about is this Linking CPT Codes to
Flow Sheet Data Elements. And so that particular workflow is actually
documented in here, and I'm going to show you that document. And
then I'm going to go through it and show you what I'm talking about.
So here's what it actually looks like. So it's going to take you, step by
step, how to access your flow sheets module, how to access the field and
data element that you need to link a PPT code to. The Report Guide will
tell you what codes are required. Once you select the code you want to
link your flow sheet field to, then you'll be able to follow this document
and do that. But I'm going to go through it today while we're on the
webinar.
Under your Run menu, you have your flow sheets, and then if it comes
up and it asks about wanting to do results, we're not going to do that
right now. I'm going to go ahead and pull up the flow sheet (inaudible)
that appear. Now, our Product Department has done a lot of work on
this flow sheet. If you'll notice, there's a whole lot of new fields in here.
I've applied the new content update that's our on our Support Center
now. It's called the Template Flow Sheet Update, and it's going to
contain some really critical items for your PQRS reporting and your
Meaningful Use reporting.
Notice how almost everything in this flow sheet has got a code linked to
it. Where it says, "Linked to," it says, "Lab." So if I want to link a code
so that my reporting will pick it up--we didn't link everything, because in
some instances, there are so many codes that could be used, and we did
not want to make that decision for you. So instead, we supplied you with
the education to be able to link those flow sheet fields to the proper code
that you use in your clinic.
5

6. For the example today, because we do have an osteoporosis PQRS
measure, I'm going to link my DEXA to the DEXA code that I use in my
clinic when I order a DEXA, or the code that's required by the PQRS
measure to satisfy the numerator. So I'm going to edit this, and the data
element is right here. This is what actually captures the data. So that's
where we're going to link the code.
So I'm going to actually use my Search, and I'm going to edit this DEXA
data element. And right now it says it's going to have text in it. Now, I
can change that to say I want a date and time in there, or I can just
leave it as text, because there's going to be a date already associated
with this item, because whenever I get that DEXA result, I'm going to add
that DEXA result to the Preventive Care Flow Sheet with the date that I
reviewed it.
Next, I'm going to associate--it's a misnomer. It says Associated Master
Lab Code. What that means is CPT code. So I'm going to find the CPT
code that is required for this particular measure, and then I'm going to go
out and I'm going to link it to this flow sheet. And if I go up here, I can
search for it first, so I can type D for DEXA, and I can see I don't have a
DEXA field, so I'm going to create one.
It creates the short name, the description, and the flow sheet element.
All I've got to do now is link that CPT code. So all of this is automatic
when you click New. I'm going to go to my CPT Reference Menu, and
I'm going to find my DEXA code. And I'm going to pick the one that is
tied to the PQRS measure, or the one that I order, and then I'm going to
attach it. And I do believe this is the one that's most commonly ordered,
so we're going to attach it like that and Save. That's all there is to linking
a flow sheet data element in a flow sheet. And now, when I result that
DEXA, my osteoporosis measure for PQRS, will know that I've done that
and recognize that in the numerator, provided they meet the criteria for
that.
So you can add all kinds of things here, anything that meets the criteria.
If it's not appropriate for the Preventive Care Flow Sheet, you certainly
can create any flow sheet that you want if it's easier for you to document
that. I want to show you one other flow sheet that's been added to
content with that content update, and it's called Smoking Status.
So this is now part of your content. Note that it's got a really nice layout,
but it's already linked, it's already linked to the codes that are required
for Meaningful Use, and it's already linked to all the codes that are
required for PQRS. So let me show you how to use this.
Lorraine Wanham: Hi, this is Lorraine. Can I stop you for a second?
Robin Bowles: You sure can.
6

7. Lorraine Wanham: We have a question. When linking the CPT, do you need to place a
checkmark in the code, or just select it as you did in the example?
Robin Bowles: No. Just select it as I showed in the example. That checkmark puts it on
your Favorites List. That's all that does.
Lorraine Wanham: Okay. Another question as well. Can you use many different codes to
satisfy a rule, or must you select only one?
Robin Bowles: It only needs one, and so when you're linking to a flow sheet, the issue is
you can't link it to more than one CPT code. So I can show you what I've
done. We had a mini-user conference here at e-MDs not very long ago,
and what I did was I created a flu shot field for both Medicare and non-
Medicare so that I could link the Medicare one to the Medicare code, and
the non-Medicare to the normal influenza code that's used.
So you can create mimicked fields, but link them to different data
elements. But that's just going to require that you add another one in
here. So if I was going to do that, I would create a new field, and that's
a new field and a new data element. I'm going to call this Influenza, and
I'm going to say Medicare. So I know that this one is where I put my
Medicare patients. And then I want, let's see, we can put a date and
time in there. It can be whatever that data type is.
And then I'm going to go down here and I'm going to find what the flu
shot code is for Medicare. And see, I've already done this once before,
so I'm hoping it's going to let me do it again. Yes, no, it won't. And
that's how I would link it and then save it. I can't do it because I've done
it again, I applied this update, and so now it won't let me do it again
because it's gone. So that's how you do it. You just put your flu shots in
there.
So if you use multiple codes, you're going to have to create multiple flow
sheet fields. And if you don't like that idea, then just let the order satisfy
it. So you have different options. Anything else, Lorraine?
Lorraine Wanham: Hi. There was one other question. If you get a moment, if we can go
back to hypertension documentation. Could you run through an example
of how you would use the reports for that and how you would go through
the hypertension process?
Robin Bowles: Didn't I do that? Okay.
Lorraine Wanham: It's just, it popped up in the Chat that they wanted more of an
explanation, so somebody missed something. Okay, thanks.
7

8. Robin Bowles: All right, and let me go back. I'm going to go back to that, because I've
already started this other thing. So if I add Carrie Coughlin, if I add the
Smoking Status flow sheet to her chart. And this is how it's structured.
Corinne did a really nice job on this. What she did, here are your MU
codes, here are your PQRS codes, here are your interventions for MU,
here are your interventions for PQRS, and then here's the additional
tobacco history that most doctors like to document. Once you document
something in there, it's a done deal and the report can capture it.
The other thing that she did is in the Past Medical History Template right
here, she actually attached that Preventive Care Flow Sheet to the
Preventive Health Template, and it's right here. So you can actually
access and document preventive care information that patients give you.
And if I did it today, I just click New Date. But if I'm asking my patient,
"When was your last pneumococcal shot?" and they tell me, "I got my
pneumonia shot in 2007," I would have to click New Date and then I
would put 2007 in there, get as close to the date as I possibly could.
Now I have a new date and I can go right here to the pneumococcal
vaccination and document that right there. But I want to change that to
2007. There. Okay? And I had that field duplicated because I had
already created it.
And now I can actually select that data and bring it into my preventive
care, like that. The other thing that I can do is--sorry about that--I think,
actually, the way that she's done this is that you don't have to add that
old date. You can just put it here and then just document the date that it
was done. There. Like that. So I'm going to take those out. There.
Fran Otte: Robin, there's another question about why you have to enter all this in
the template and the flow sheet.
Robin Bowles: You don't have to. Yes, you don't have to enter it in both places. That's
the whole point here, is I can either enter in a year, put it in that flow
sheet, or I can use the template. So you've got choices. You can't use
the Past Medical History--you can't use the left-hand side of the chart to
document data that have to have a date associated with it. That's the
reason why we've made it so that you can access a flow sheet, get the
data in there, and associate a date with it, because flow sheets have
dates associated with them. That's their very nature. Okay? So that's
the reason why.
If you've already been doing your preventive care in a template, you
don't like the idea or you don't want to use the preventive template.
Let's say I'm already using a Past Medical History Template, and I like it
just fine. I don't want to have to go to a whole different template to get
to that flow sheet. You can add that flow sheet to any past Medical
History Template you want to. So if you just take the template that you
have, that you're using for past medical history, and you want to be able
8

9. to access that Preventive Care Flow Sheet from that template, you're just
going to go into Editor mode, and you're going to go to New, New Item
Under, and you're going to create a flow sheet.
And then right here I'm going to type Preventive Care Flow Sheet. Under
Generated Text, I'm going to remove that, because I don't really want
that necessarily to print in my notes. However, I could say Preventive
Care History. I could say something like that if I wanted that to print.
And then I could hit my Enter so that that information drops to another
line. If you don't want it to do that, you don't have to do it that way. So
I'm going to drop to another line and put my caret in there.
Next, I'm going to go to the flow sheet and I'm going to say, "Bring up a
single flow sheet." Which flow sheet do I want? I'm going to click this
ellipses right here, go find my Preventive Care Flow Sheet, and select it.
And then I'm going to say, "Okay, that's all you've got to do." And now
you can add that flow sheet in any template you want, and then you can
sequence it. You can put it wherever you want. So I want it up to the
top. I might have to push it a little ways at a time. And then now I can
get to it from my Past Medical History Template.
And if I'm going to document information that's in there, I can check it
and select it, and now it's part of my Past Medical History. Now, I think it
formats very nicely, so this is the date it was documented. One is the
date it was documented and one is the date that it was done. Okay?
Any flow sheet can be amended like that, and you can attach CPT codes
to them so they can capture dated information for your PQRS reporting.
All right.
We're going to do a visit for Carrie Coughlin because she needs to appear
on our report. The very first thing I have to do is make sure, does she
have two visits within the reporting period? And she's got this one today
and she's got one on 10/5. She's also got some in September.
I need to make sure that she had a hypertension diagnosis. So again,
I'm going to look at her current problems and see if she has
hypertension. And it doesn't look like she has a current hypertension.
Hyperlipidemia, diabetes--there she is, there's her hypertension. So
we've got hypertension, she has the correct diagnosis. I don't have to
bring it into a visit note. That's not required.
So I'm going to go here and she could be in today for, she could be
coming in today for a sore throat, and I would document my sore throat.
But the main thing that it's looking for is it wants to know, did I take
systolic and diastolic blood pressure values? So I'm going to go ahead
and I'm going to put in her weight, and then I'm going to put in her
9

10. temperature, and I'm going to put in her blood pressure. And then I'm
going to save. And that's all that's required for the report.
And then I have to make sure that in my plan that I add an E&M code so
that the report can capture it, so I'm going to go ahead and plug in a
99214 in there. Normally, you would use your E&M code to do that. And
that's what's required for the report. Okay? And I don't know if the
report parameters changed for that report, but we'll give it a shot. I'm
not scared. We'll run our PQRS dashboard and see if she shows up on
there now.
Now, we did not do blood pressure both times, but it just needs to be
documented at one of the qualifying visits. So we're going to go back.
And she was the only one that hit our report. And there. And then I'm
just going to run this for Dr. Kildeer this time, and we're just going to run
that one measure. And now she's in there. Yay!
So now I can see she's in there once, but she also has other qualifying
visits because she's been seen more than twice this year. All right. And
that was actually what I think the person that sent this question in
brought up. This is not--remember, this is the 2011. This is not the
actual current 2012 measure. So as long as you've got patients that are
hitting the report, if the number is not right on the 2011 report for this
measure, don't worry about it, because the 2012, hopefully, will have
corrected that. Because I don't think that they should be in there more
than once. They should only qualify once. Okay.
And I believe that was the question that I got. So you're right. It is
counting them more than once, so the 2011 report's not right. But as
long as you're getting a numerator for your patients that are in your
denominator, that's what you're looking for. And then the 2012 report
should not do that. And I'm actually, I'll make sure Corinne's aware of
that after we get off the phone. Because she can double-check to make
sure the 2012 report's not calculating that same way.
All right. I had a question about how to deal with the patients that are
not hitting the report. So I'm going to go ahead and run that dashboard,
and we're going to take a look at a couple of different measures. And
we're going to look at, "How can I address those patients that should be
hitting the report, but they're hitting my denominator, but they're not
getting in my numerator, and I need to find out why that is?" And we
have to use the 2011 right now because we don't have the 2012 yet.
I have been able to successfully use the registry processor for certain
measures to be able to pull up data, just to make sure I'm getting data.
So we're going to just run this for one doctor. We're going to run it for
Dr. Killdeer, but we're going to run all the measures. Any questions at
this point, Lorraine?
10

11. Lorraine Wanham: Hi. There are a few in the Chat function. Do you want me to read, or do
you want to read them? Whatever's easier for you.
Robin Bowles: Oh, let's see. Okay. "The 2012 report should also calculate the
percentage of visits where blood pressure was reported. So it is correct
that patients will appear for each visit as long as they had at least two
visits."
Okay, thank you, Sandra, I appreciate that. So the report's not broken.
And, "When will the 2012 PQRS reports be available?" I addressed that
at the beginning of the call. I believe it's either going to be next week or
the week after that. That's as specific as I can get at this point.
"The blood pressure measure requires that blood pressure be
documented in every visit, not just one. It requires two visits." Yes, so
that's what you said. It's going to count it every time. And I did not
realize that, so thank you for that clarification.
"Why is smoking broken out into MU and PQRS?" Because different
codes are required for Meaningful Use than are required for PQRS. We
were required to write specific descriptions for smoking statuses for
Meaningful Use, and so we had to create custom codes for those specific
codes. They don't match one-to-one with the PQRS descriptions, so
that's why there's two different sets of codes. That was definitely not our
choice. That came from CMS, and we just followed the rule.
I also have a question about, "Is there an advantage to using a flow
sheet versus the template?" The benefits to flow sheets, I think, number
one, is they're very easy to create, they can be tied to a code, they can
have a date associated with them, no matter where they're used. So
even on the history side of the chart, I can tie a date to it. That's the
main advantage. Other than that, it really depends on the doctor's
workflow. Again, we're talking about you need to make the software
come to you. What your workflow is, that's what you want to use. But
what we've done is we've just created more logic to make it easier for
you guys to get the data.
And then I've got something that says, "The column date on the flow
sheet was used to determine the measure logic," and that she was told
putting the date in the field of the flow sheet would not calculate the
correct date. And I'm going to have to check with Corinne on that. I'm
not absolutely positive on that. Quite frankly, that was my understanding
as well, that I had to put a new date in the flow sheet. But when she set
these flow sheets up, she set them up to put a date in there. So that's
why I kind of flipped there and said--so I'm going to have to find out
11

12. about that, and we'll get the information to the QIOs, and then they can
get the information to you. I'm going to have to check with her on that.
Let's see. This documentation for PQRS will be available, it will be
available next week on the Support Center. You'll have a new button out
there that says PQRS Resource Center. The Numerator Methodology
Document, we've already sent to the QIOs, so your QIOs have that
document already, but it will be available on our Support Center along
with the first 25 PQRS measures. We will be finishing the other 22 over
the next week. So it's probably going to take us a week or two to finish
up the other 20. But those first 25 were the ones needed by the QIOs.
They're the most common ones being used by the providers using our
software, so we started with those and we got those out first.
All right. So let's go ahead and look at how to manage the patients that
are not hitting your numerator. So, for instance, on this one right here,
the Preventive Care and Screening, I have two patients out of four. Why
is that?
The first thing I'm going to look at is who are those patients that were in
the denominator but did not meet it? And so here's your "Not" page.
I've got these two patients that didn't get in the numerator and should
have been in there. They meet the age requirement, they meet all the
other requirements. So why is it that they didn't?
So at this point, I'm going to take these two patients, and I'm going to go
back and look at their charts. Was it just that we forgot, we didn't
document their refusal? Could that perhaps be it? So I'm going to be
looking at those charts and finding out what we did not document.
Now, for reports that do allow for either inclusion or exclusions because
of a circumstance that may have prevented you from performing that
action on that patient, you have modifiers that have to be used with the
PQRS codes, the 1P, 2P, 3P, and 8P. And so if that's a common scenario
that happens and you want those patients included, that's got to be
documented.
So for instance, this patient was one of the ones that should have had
one but didn't. So how can I get him to hit the report? If it is allowed as
an exclusion, so I'm going to go back into one of his notes, I'm going to
go down to the plan, and you've got a couple of different options here. I
myself think that if I have decided which measures I'm going to report
on, I know the PQRS measures I'm trying to hit. My recommendation
would be to add that information into either a Current and Future Orders
template or place a jump in here to a PQRI template and give yourself all
those codes.
12

13. And so, for instance, on my immunizations, if they refused that
immunization, it's possible that I could add a refusal section here, or I
could build a refusal section, and I could include all my codes. And then I
can attach the correct modifier. So if I'm going to build something like
that, I'm going to go ahead and build something like Refusals. And
there's actually one in here. I went and found it, and I copied it for a
doctor yesterday.
And then I can go and build the next level with all of the codes that I
need for my refusal. So if they refused the pneumococcal, if they refused
their colonoscopy, I can record that with my Rules Manager, but it
doesn't document a code for me. So that's where, in order for the report
to capture it, I've got to have a refusal code in there.
Okay. And so if I'm going to build something like that, and I'm going to
say that they refused their influenza, and I'm trying to remember which
ones allow for that, and that's why these documents are so important for
you guys is that it will actually tell you whether you can use that or not.
So I'm going to go ahead and look at the influenza one, and I'm going to
bring it up on the screen so that we can check that out. All right.
So here's the influenza. And as far as exclusions go--yes. If they're
allergic to the vaccine, that would exclude them from the report, meaning
they'll be excluded from the denominator and the numerator. So this one
doesn't really, it doesn't indicate that it's going to allow that. This one
hasn't been vetted yet, so I've got to make some changes to it.
So here are the--okay, the 4037 1P, 2P, and 3P. So if they had an allergy
to it, and one of these codes is documented in their current problems,
then that report will exclude them. If I document that they were refused
for a medical reason because they're allergic to it, I'd rather do that than
document that they have an allergy to one of the vaccine components
and add that in their current problems. I can do it that way. So you
have two different things that you could possibly do here.
I'm going to go ahead and show you how to put that refusal code for a
medical reason into your template. So we're going to need a 4037F 1P.
So under my refusals, I'm just going to build 3P, influenza for medical
reasons. And I don't even have to really say why. And then what I'm
going to do is tie that code right here. And here's my 1P. And then I'm
going to say okay.
So now, if they refused something, it becomes a whole lot easier for me
to document that refusal and get that patient off of the report as a Not.
Okay? See if I've got any questions. That should have generated lots of
questions.
13

14. And I'm not saying that you have to go back and correct your
documentation. The PQRS measures and the requirements for those
have been out for a while, so the codes that were needed have been out
there for a while. So if you haven't been adding them, then you're going
to have some patients that aren't going to meet that.
But I guess the point I was trying to make was it's sometimes just a
workflow thing; somebody's not documenting something they should.
Sometimes it's missing content; it's content that you need to add to make
it easy to get documented. So going back and looking at patients that
should have been in the numerator that weren't allows you to change
your workflow or do whatever you need to do to make sure that you are
capturing that data.
Let's see here. Let me go to the top. Okay. Okay. I think I've got all
the questions now. So that basically should take that patient out of the
report now. Let me look at what's next here.
And there was a question about whether or not the reports would show
an 80% threshold. And I think you saw how the reports did for this year.
Whether or not the new reports show that percentage or not, I don't
know that. I don't know that. I could calculate that manually fairly
easily. I do know that because you're going to be submitting through a
PQRS engine that was developed for QRDA, it's going to, it will have that
calculation in it. And the example that I'll give you is--and I had one out
on my desktop earlier, but I don't think I still have it--the clinical quality
measures, when you created that electronic file. And let me just show
you all what that looks like, because I believe the new engine will look
very similar to that.
So if I run this, and then I'm going to do my tobacco and my flu shot, I'm
going to do my breast cancer, and I want my colorectal cancer screening.
To me, these are easy, low-hanging fruit for primary care. You already
do this anyway, so you might as well.
So if I run this, and I can go down here, and then I'm going to run it for
this year. I want to show you what this XML file looks like, because I
know the new one will be very similar to this. It may not be--just so that
you understand that it will have all that information in it.
If I go out here and I look on my desktop, here's my QM file, and it looks
like this. But what you're going to do, you can go down and you can find
the measures pretty quickly. So here is Measure Number 13, that's your
hypertension. I have four eligible instances, one that meets the
performance instance, none excluded, and three that did not meet. The
reporting rate is 100% of the population, and the performance rate is
25%. So QRDA requires a certain format, and I believe this is all the
14

15. information that will be contained in that file that you upload to CMS.
Hopefully, that answers that question.
Oh, I hope I did not just close this session. All right. Let's see. I already
addressed that one. There were some questions on the smoking report,
and I went into a lot of detail on this last time. So there may be some
new folks on the call, so I'm going to go in and repeat that.
For Meaningful Use, the codes that are required are different for smoking
status. Where most people are having trouble is getting the cessation to
count. And so you've got a couple of different options now. Number
one, most important, it must be done in the note. The cessation and the
smoking status have got to be dated information and documented.
That's one reason why that flow sheet was created, so you can use a flow
sheet to do it, or you can do it in your notes. And let's say I'm going to
use, if you go down to the plan, and the Current and Future Orders Plan
has this.
Notice this is another change that was made with this new flow sheet
content update. Referrals now it has an orange star, because that's your
outgoing transition of care. And here we've got smoking status, and
that's the old one, but now you have a new one right here. It's got an
orange star. And so if I document it here, it's going to actually, that's all
Meaningful Use stuff.
If you go to the smoking cessation, all of the plan templates now have
this additional information in them. So if I'm trying to hit PQRS and--we
did not make the rules here. There are two different code sets being
used for Meaningful Use for your quality reports and for Meaningful Use
for PQRS. They are different codes, and they are different code sets. So
that's the reason why we just put it all on a template for you. If you
have to click it twice, I apologize, but that's what it requires.
The PQRS measure for cessation counseling requires 99406 or 99407.
And I thought maybe that was a mistake, so I went and looked at the
Code Master just to make sure, and those are the only two codes it's
querying for--no G-codes, which kind of surprised me. So those are the
codes that we put in this template for you. So it's all right here for you.
And once I do that, then that patient will hit my report. And that's all in
this new Content Update that's out there. Previously, it just had to be
done, it had to be done in a note, and those codes were there. They
were all in this area right here. So they've been there for a while. So if
you were documenting them there, then you should still be getting credit.
But it may depend on what codes are attached there. So right now, mine
has a G-code in there, but I created that. That wasn't e-MDs' content.
So if I'm going to do PQRS, I need 99406 and 99407. If I'm going to be
15

16. doing this clinical quality, then I can include the G-code. It queries for
both, but PQRS only queries for 99406 and 99407.
Fran Otte: Robin, just a reminder. We're about five minutes until the hour.
Robin Bowles: Oh, wow.
Fran Otte: I know. It's gone quickly. So if any of you are able to stay on any
longer, we have allotted some extra time at the end, but we understand
that some of you maybe need to go at one due to other obligations, so
thank you.
Robin Bowles: Yes, and I noticed that on the Chat, Lorraine said if you include your
email address in the state's name, she forwards that to me. If you have
questions, I'll get each one of you answered, even if I can't address them
all on the call. And if that requires that I need to pick up the phone and
call you, I'm happy to do that. I'm here as a resource for you, and I will
get you the answer that you need.
Let's see. And then I had a question about, "How can you see the codes
that's attached to an item in a flow sheet?" And what you have to do is--
so some of them may be already attached, but you don't know what code
they're attached to, and you want to know. And so I'm going to go
ahead and open up that Preventive Care Flow Sheet again. And let's see.
For instance, on my DEXA. So no, it wasn't the DEXA, it was the flu shot.
I was trying to create another flu shot field. So if I create the one for the
Medicare--actually, no. Let me just go look at the DEXA so you can see
how you can see that.
So I'm going to just edit that field. I'm going to click on the Search for
the data element, and then I'm going to edit that data element. And
right down here is where this Master Lab Code is, and so if you do that,
and then you type in D for DEXA, it will show you the codes right here.
So those are the actual CPT codes that are attached to the data element.
And then you just back out of it, and it will leave it like it is. Okay?
There was a question. It's been on here a couple of times, so I want to
go ahead, and I'm just going to reiterate your codes for smoking, and I'm
going to go ahead and just bring up the guide for the smoking measure.
I think it's done. Let's see. That's mammograms. And there it is right
there. Okay.
So this outlines the codes. And if any of you are in desperate need of
this, if you will get that information to Lorraine, she will get me a list of
people that need this, I'll just send it directly to you. We won't wait on
the Support Center. I'll just send it to you.
16

17. So this is talking about Numerator A and Denominator A, because there's
a numerator and a denominator, and there are two in this measure. So
the first one is going to be all patients greater than or equal to age 18 at
the beginning of the measurement period and that have two of the
following visit cases. So it's looking for any two of these. Or, and there's
a lot of them like this. They go into this crazy detail about how many
visits and what kind of visits. So this allows for one visit of any of these
kind. So you really have to look at the code set.
Now, the CPT codes that are in the chart note that identify patient's
smoking status are these. So only smokers are counted in this
denominator, not all patients. I believe that's the way that works. Yes.
Numerator B is going to be patients 18 or older that had cessation
counseling within 24 months of the visit. So that indicates it's got a two-
year look-back from the visit note, and it's looking for that 99406 or
99407. And this indicates that they're looking for the G0436 and G0437.
And then here's your Denominator B and your numerator information for
that. Oh, I always do this, because I didn't do this one, so I'm not as
familiar with it as I am with some of the others.
Oh, this is the one that's looking for a medication, so either an active
medication, an existing medication in their current medications, or an
order for a medication, which would be either a prescription or a refill.
And it's going to have to have a date on it, so it's got to be done within a
visit note. It can be done in current medications for a refill, but it's got to
be able to report it for the date, that that was done.
Let's see. So Numerator B is looking for cessation counseling or that
cessation was done via a medication. And then these are the codes it's
querying for in this specific report. There's another report that only
queries for 99406 and 407. So it just depends on which smoking report it
is, because believe it or not, they were all different. And then we give
you some workflow options for how to get that information into your
chart notes so that it can be counted and queried by the report. Okay?
Operator: There is a question on the line.
Robin Bowles: Okeydoke.
Operator: And as a reminder to everyone, if you do have a question that you'd like
to voice, please press the number seven on your telephone keypad.
Questions will be taken in the order they are received. And if at any
point your question has been answered, you may press seven again to
disable your request. If you are using a speaker phone, we do ask that
while posing your question, you could pick up your handset to provide
favorable sound quality. The question on line is from Shirley Laidley of
Ohio. Go ahead, Shirley.
17

18. Shirley Laidley: Hello?
Robin Bowles: Yes.
Shirley Laidley: Oh, okay. Basically, I was wondering. You said that you would be
sending out these measures to all of us?
Robin Bowles: Yes, if you've given your email address, that will be forwarded to me, and
then that way I can send you the documents. If there's specific
documents that you need, but otherwise I'm going to send you whatever
you've requested in the email.
Shirley Laidley: Okay, thank you.
Robin Bowles: So I can get those to you sooner than they'll be reported on the Support
Center, if I know who you are.
Shirley Laidley: Thank you very much.
Robin Bowles: You're welcome. And then I had a question that said he was confused on
whether the orange or green was for PQRS. So PQRS is green;
Meaningful Use is burnt orange. So that's the difference between the two
attributes. So if you're doing PQRS, you're going to click on the green. If
you're doing National Quality Forum Measures for Clinical Quality
Reporting, you're going to do the orange. I think that's it for questions.
Operator: We have another question on the phone line.
Robin Bowles: Okay.
Operator: From Madonna Francois. Go ahead. Madonna, your line is unmuted. If
your phone is muted on your end, please unmute it and state your
question.
Madonna Francois: Sorry about that. I was just asking for the code list.
Robin Bowles: That's in the Report Guide, so I'll send it to you.
Madonna Francois: Yes, the documentation that you had on the screen a few minutes ago.
Robin Bowles: Oh. Yes.
Madonna Francois: That's what I wanted. Thank you.
Robin Bowles: You bet.
Operator: Again, as a reminder, if you do have a question, please press the number
seven on your telephone keypad.
18

19. Robin Bowles: Let's see. So if it's Numerator B that you're trying to hit, these are the
code sets. These codes right here, which are your cessation codes for
PQRS, and then these are all the medications that it queries for.
Operator: There's a question again from Madonna Francois. Go ahead.
Robin Bowles: Okay.
Madonna Francois: Sorry, for some--
Robin Bowles: Yes. I see the question in the Chat. I've got a question that says, oh,
from practices that have already tried to update the templates to meet
PQRS themselves, how will the template update affect them if they run
it? That's a really great question, and thank you for asking it. If you
have edited a template, anything that you have created is automatically
blocked from update. Okay, if you edited that item and created your
own, it is not going to update that. So you're okay. You're safe.
And then there was a question that says, "Can you please explain why
effective date has to be entered in for EHR direct reporting?" Effective
date. I'm not sure. Andrew, if you can just kind of tell me what you
mean by effective date. Are you talking about the measurement period
date? No, the effective date on the Medicare card. I don't know. I don't
know why. I can't answer that question. That would be a question
probably more for CMS. If it's required, it's for the file, then we were
required to query for it. But why they're requiring that, I don't know.
Unidentified Participant: Hi, Robin. This is Kieran from MassPro. I'm here with Lorraine. I
have a question on the XML report that you generated. Would you go
back to that?
Robin Bowles: About the XML report? You want to show it one more time?
Unidentified Participant: Yes, if you can go back to that, I have a question about that.
Robin Bowles: You bet. This is last year's, by the way, but yes, this is--.
Unidentified Participant: This one here has two kinds of rates. It says performance rate
and then a reporting rate. What are those two? Could you please
explain that to me?
Robin Bowles: Yes, I can. The reporting rate is, of the qualified population, how many
of them are you reporting on? And we're reporting on 100% of the
patients that qualify. And then the performance rate is what was the
actual threshold that you hit.
19

20. Unidentified Participant: So if there are exclusions to the denominator, then the reporting
rate would not be 100%? Is that right?
Robin Bowles: No. Exclusions don't count against that. Exclusions are not included in
the denominator at all or the report.
Unidentified Participant: Is the reporting rate always going to be 100%?
Robin Bowles: Yes, probably so. At least that's my knowledge of that. Now, this is not
the current year's file. Whether or not the one for this year will generate
like this, and if that's something that's still in that QRDA file, I don't know
yet. Hopefully, I'm going to get a look at it next week, but I've not seen
it yet.
"Does the PQRS denominator include Medicaid patients also?" No, I don't
believe so. PQRS is specific to Medicare. So it's only pulling Medicare
populations.
Lorraine Wanham: Hey, Robin, this is Lorraine. I just want to make sure that we get on the
recording that if anybody needs any follow-up information, they can
contact IHPC, which stands for Improving Health for Populations and
Communities, IHPC@MassPro.org, and someone would get back to you
and get your information out to your state QIO for follow-up. It's in the
Chat. It's been posted. But I just want to make sure we get it into the
recording.
Robin Bowles: Yes, thanks, Lorraine. I appreciate that. And you'll forward that to me,
right?
Lorraine Wanham: Of course.
Robin Bowles: Of course. You've been so wonderful. Thank you. I did get a question
that says, "Can we run the XML file to see where we are now?" That is a
really large file, and I don't recommend running it. Yes, no, I don't
recommend running it. Plus it's not going to really be as representative
as you would like it. The only reason I showed it was so you could kind
of see how the report is formatted, because the QRDA formatting, I don't
think, has changed completely. But it should be very similar.
"One of my offices has Medicaid patients showing up on the detail." If
they're Medicare secondary, because it does include secondary and
tertiary Medicare.
"Robin, when generating the PQRS dashboard report, if a physician's
name is not listed, how do you add the physician to the list?" Oh, my.
That must mean that physician is not active in the software, so I'm not
really quite sure how they would not be showing up on that list. I think
20

21. you need to create a support ticket for that. I can't diagnose that on the
phone. If I could, I would.
And actually, on the performance rate, like I said, I don't really know on
that particular one. That was actually CQM, that particular file, so it
wasn't even looking at PQRS. So as far as e-MDs check performance,
sure, 100% of applicable patients are included, the PQRS file may not
have that. I don't know. What I wanted to show you was that it will
show exclusions, it will show included patients. Mostly, I just wanted to
show you the format.
"If the effective date of Medicare insurance is missing, Corinne said the
report won't include the patient in the file transmitted." So that's
probably good information for you guys to have. That effective date for
their Medicare has got to be entered into the patient's insurance
demographic if you want them on the report.
Let's see. "And where do we find the S-codes and their explanations?
I'm not finding them in my HCPC (inaudible) notes." You probably
wouldn't. You can check your HCPC reference, but we created them as
custom CPTs. And so if you look at the PQRS measure and the codes
that are being queried, that's how you're going to find them. That's why
these documents are so important.
And I'm trying to get them on the Support Center as quickly as I can.
They're ready to go. We're having some issues with the person that does
all that. So I've got them all to him. I've explained how important it is to
get them out there. We've given him screen shots of how we want it to
look, so I'm hopeful that they're going to be out there very, very soon. If
I can get them out there today, I may walk down there. I can just call
and walk down there and say, "Hey, look. Please get them out there
today, in whatever way that you can," so that you guys can start looking
at this.
The CMS measures and the actual CMS measure specifications will also
be out there, so we're going to give you a link to those specifications
from the CMS website that you can download as well, so you have their
explanation of the measure as well.
But like all your PQRS stuff, and I don't know--I don't know how they
have them linked in here. Like I said, if I know what the reporting code
is, then I can look it up here in my Search. But if you don't know what it
is, then I get what you're saying. It's hard to look it up if you don't know
what it is. So you definitely do need to get that information, and it's
listed in the PQRS Measure Specifications out on the CMS website. But it
will be listed in our documents as well.
21

22. Access to the Support Center--talk to your Senior Rep at the QIO,
because all of our QIOs have access to the Support Center, and they can
give you the information on getting logged in.
Operator: There is a question on the line.
Robin Bowles: Okay.
Operator: From Richard Blate of Georgia. Go ahead, Richard.
Richard Blate: Hey, thanks for this. This is helpful, as always. A couple of questions.
The effective date for the Medicare insurance policy--is that something
new for PQRS at that level, or is it how you all are programming the
reports to go? And the reason that I ask that is that the first time I heard
it was a communication that Corinne had sent to all of us. And secondly,
I've seen a scenario where a practice has a chart, but they use something
else for the practice management piece. The two products are kept
separate with no connectivity between them. But the practice did set up
insurances inside of the chart so that they could track it and things from
that side.
Robin Bowles: Right.
Richard Blate: And then the NQF, and we ran the PQRS dashboard report, and it came
up with nothing. And then we ran the NQF reports, and there's data all
over the place.
Robin Bowles: Yes, yes. And I've got two explanations for that, and that's as much as I
can give without looking at the specific scenario. But even though it
looks like, when you look at, let's say, the Final Rule for Meaningful Use.
The documentation puts the PQRS and the NQF report numbers side by
side, like they were synonymous, and they're not. They are different.
The requirements are different, the code sets are different. And so what
may show up on an NQF report for that very, very similar measure in
PQRS, you may have different code sets.
Now, if the code sets are exactly alike, which I found very few of them
that were like that, because I did a comparison of every single one of
them when I was working on the Clinical Product Team. So they're
different enough that the queries could not be identical. Otherwise, that
would have been a piece of cake for us to develop, and we wouldn't have
had to have gone through everything we've gone through. So that's kind
of my answer for that.
The other thing is, the 2011 dashboard, I believe, was updated for things
like the flow sheet logic and stuff like that, but it doesn't contain, if the
measure changed, it won't contain that. And so there may be changes to
the query if there were any problems with the 2011 that we found out
22

23. about later, that may be corrected in the 2012. So that's really as good
as I can answer that question until I have a new dashboard to run.
Richard Blate: Okay. And then my other question is more functional. Like going back to
the HTN measure and the blood pressure, if someone in the practice just
completely free-texted all of that information into the note and the note
has been locked, can they go back in and edit the note to put in the
historical data in there correctly?
Robin Bowles: No.
Richard Blate: Or how would that be done? Can it be done, and then how?
Robin Bowles: I don't know of a way that can be done. They could try, using the Vitals
Flow Sheet and entering that information directly into that flow sheet and
using that date of that visit. They could try that. I don't know if it would
work or not.
Richard Blate: What about an addendum?
Robin Bowles: Nope, that's text. Can't pick it up. Sorry. And then they need training.
They need to get with somebody and get some training so that, you
know, going forward they can do things so that their reports will capture
it.
Richard Blate: Thank you.
Robin Bowles: You're welcome. Sorry I couldn't provide more helpful advice.
Lorraine Wanham: Okay, this is Lorraine. We're at, let's see, 2:20 if you're on the East
Coast, 1:20 for Central. I think we can only take one more question,
Robin, if you still have the time, and then we're going to have to call it a
day.
Robin Bowles: You bet. One more.
Lorraine Wanham: If anybody has a question.
Operator: Again, as a reminder, if you do have a question, please press the number
seven on your telephone keypad.
Robin Bowles: Maybe we don't have any more questions.
Lorraine Wanham: Okay, I'm going to call it, then. Thank you, everybody. Once again, if
you have any other questions and you want to use me as a point of
contact at IHPC@MassPro.org, I'll forward any information on to Robin or
to your QIOs as it would deem appropriate, and hope we keep everybody
23

24. informed. And our next session we're planning should be some time in
December. Don't have a date yet.
Thank you, Robin, and we appreciate e-MDs providing this opportunity.
Goodbye, all.
Robin Bowles: Thank you. Bye-bye.
Fran Otte: Thank you, and 'bye.
Operator: Thank you. This does conclude today's teleconference. We thank you
for your participation, and you may disconnect your line at this time.
24