PRIMARIS NEWS
June 2014
Primaris Services

Will your security risk analysis pass an audit?

Primaris can conduct a thorough security risk analysis, providing:

  • Recommended remediation action
  • Facility walk through notes
  • Sample security policy
  • Privacy security breach reporting management plan
  • Recommendation for obtaining ongoing security updates

 "I recommend Larry Henderson and Primaris for your Security Risk Assessment requirements.  Larry conducted a thorough and understandable Security Risk Analysis for us the last two years.  He pointed out risk issues we would otherwise overlook.  We recently underwent a CMS EHR pre-payment audit and were asked for proof of Security Risk Assessment.  The information Larry provided helped us pass the audit." -Hannibal Clinic

 

Join us for a webinar on July 15, 2014

12:15-12:45 pm

Register here

 

To learn more or schedule you risk analysis, email Larry at [email protected]

  

Primaris also offers data abstraction services to support reporting for the GPRO Web Interface.  Click here for more information or contact Cora Butler ([email protected]).  

 

In This Issue
Male dr talking to patients
Female dr talking to patients
reporting Clinical Quality Measures Using a Qualified Clinical Data Registry 

The Qualified Clinical Data Registry (QCDR) is a new reporting mechanism for 2014 PQRS.  A QCDR is a CMS-approved entity that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients.  QCDRs report PQRS to CMS on behalf of participating members.  CMS recently published the listing of Qualified Clinical Data Registries for 2014 PQRS Reporting, along with services offered, measures reported, costs and contact information. 

 

A QCDR is different from a qualified registry in that it is not limited to measures within PQRS.  QCDRs may include up to 20 measures that are NQF-endorsed, current PQRS measures, measures from CG-CAHPS, and/or measures used by medical boards, specialty societies or a regional quality collaborative.  Also, a QCDR reports quality measures across payers, and is not limited to Medicare patients.  The QCDR option is only available to individual Eligible Providers (EPs), not to groups.  Specialists may be particularly interested in using the QCDR option, since traditional PQRS measures are not always applicable to their patients and/or practice.

 

Similar to other methods of PQRS reporting, to earn a 2014 PQRS incentive using a QCDR, EPs must report at least 9 measures covering 3 National Quality Strategy (NQS) domains for at least 50% of their applicable patients, and at least one measure must be an outcome measure.  QCDRs classify each of their measures into the appropriate domain.  To avoid a PQRS payment adjustment in 2016, EPs must report at least 3 measures covering one domain for at least 50% of applicable patients.   Once an EP selects a QCDR, he/she must work directly with the QCDR to meet all PQRS reporting requirements.

 

The QCDR may also be used to avoid a payment adjustment under the Value-Based Modifier (VBM) program in 2016 for groups of 10+ EPs who do not self-nominate as a group.   As discussed in prior newsletters (see January 2014 Monthly Tip , Step 6), groups that do not self-nominate as a group may meet the VBM reporting requirement if at least 50% of all EPs report as individuals under PQRS.

 

EPs reporting PQRS using a QCDR may also satisfy the clinical quality measure component of Meaningful Use if the following conditions are met:  (Check with the QCDR for specific requirements.)

  • The QCDR is certified for 2014 Meaningful Use Reporting (check the Certified Health IT Product List) and is included as part of your complete EHR; and
  • The EP must report eCQMs from the list of 64 approved eCQMs for Meaningful Use.  QCDRs that have sought 2014 Certification for Meaningful Use must include at least 9 of these eCQMs covering 3 domains of care.

For more information on reporting using a Qualified Clinical Data Registry, please refer to QCDR Participation Made Simple.

PROPOSED 2014 EHR INCENTIVE PROGRAM CHANGE
CMS and ONC released a notice of proposed rulemaking (NPRM) that would allow providers participating in the EHR Incentive Programs to use EHRs that have been certified under the 2011 Edition, a combination of the 2011 and 2014 Editions, or the 2014 Edition for calendar and fiscal year 2014.   Providers in Stage 2 could also elect to continue with Stage 1 in 2014.

 

The intent of the NPRM is to grant flexibility to providers who are experiencing difficulties fully implementing 2014 Edition CEHRT to attest this year.   The rule also proposes to extend Stage 2 through 2016, meaning the earliest a provider could enter Stage 3 would be 2017.

 

The table below shows the 2014 Participation Options for providers, if the proposed rule is finalized.  Please remember this is only proposed: As of right now, the only providers that will be able to attest for Stage 1 or Stage 2 in June are the ones ready to use the 2014 Edition Certified EHR Technology.  The 2013 version is part of the proposed rule change and that is under evaluation.

 

You would be able to attest for MU:

If you were scheduled to demonstrate:

Using 2011 Edition CEHRT to do:

Using 2011 & 2014 Edition CEHRT to do:

Using 2014 Edition CEHRT to do:

Stage 1 
 in 2014

 

2013 Stage 1 objectives and measures

2013 Stage 1 objectives and measures 
-or- 
2014 Stage 1 objectives and measures

 

2014 Stage 1 objectives and measures

Stage 2 
 in 2014

 

2013 Stage 1 objectives and measures

2013 Stage 1 objectives and measures 
-or- 
2014 Stage 1 objectives and measures 
-or- 
Stage 2 objectives and measures

 

2014 Stage 1 objectives and measures 
-or- 
Stage 2 objectives and measures

 

 

For more information visit the CMS Newsroom.

ANNOUNCEMENTS

Update: Certified Survey Vendor Option for PQRS Reporting

CMS recently decided it will administer and pay for the costs of doing the CG-CAHPS for any group of 25 or more EPs who elect to use a Certified Survey Vendor for 2014 PQRS reporting.  (Previously, CMS was only intending to pay for and administer the survey to groups of 100+ EPs that report using the GPRO Web Interface option.) Please see the notice and Fact Sheet for more information.

 

Evidence-based Weight Management Program Training:  Million Hearts and the Department of Veterans Affairs will be discussing VA MOVE! �, a national evidence-based weight management program for Veterans that has helped over 500,000 people lose weight, keep it off and improve their health.  The program is based on the National Heart, Lung and Blood Institute Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults and recommendations from the US Preventive Services Task Force.  The program is on June 17, 2014 from 4:00 - 5:00 CST. Target Audience: Physicians, Nurses, Social Workers, Pharmacists, Psychologist, Social Workers, Dietitians.  Join live viahttps://va-eerc-ees.adobeconnect.com/_a1089657440/r986kt50yrh/ Enter your first and last name upon entering the room.  Audio is available through your computer (VoIP) or by dialing 1-800-767-1750, Access Code 49114#. 

 

Power of Music Documentary Screening

You are invited to attend a free screening of "Alive Inside," Sundance Film Festival award-winning documentary about the power of personalized music to restore neurological function and quality of life to nursing home residents with Alzheimer's disease and other conditions.

  • June 11, 2014 - St. Louis (Des Peres 14)
  • June 12, 2014 - Lake Ozark (Eagles' Landing 8)
  • June 13, 2014 - Bethany (BigTime Cinema)

Stay after the film for a live question & answer session with Dan Cohen, MSW, founding Executive Director of Music & Memory. Advanced registration is not required.  CEUs available. To learn more, visit http://musicandmemory.org or  www.momc5.com to download the flyer!

 

CMS has released three new video presentations on PQRS, the Value-Based Payment Modifier and the EHR/Meaningful Use Incentive programs are available at the following links: 

 

Title: CMS Physician Quality Reporting System: What Medicare Eligible Professionals Need to Know in 2014

URL:  http://youtu.be/-P0ya_YbLMw

 

Title: The CMS Value-Based Payment Modifier: What Medicare Eligible Professionals Need to Know in 2014

URL:  http://youtu.be/_E4O3ZlMfbw

 

Title: Medicare & Medicaid EHR Incentive Programs: What Medicare & Medicaid Providers Need to Know in 2014

URL:  http://youtu.be/wqbej222Lbs

HEALTH OBSERVANCES

June is National Safety Month!  There are six electronic clinical quality measures (eCQMs) that address the Patient Safety domain.  Certified EHR technology may contain some or all of these measures.  Find out which measures your EHR is certified to measure and report, then establish processes for your staff to capture all needed data elements.  Click here for detailed specifications for each measure.

 

PQRS #

NQF #

eCQM#

Measure Title

PQRS 0130

NQF 0419

68

Documentation of Current Medications in the Medical Record

PQRS 0192

NQF 0564

132

Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures

PQRS 0238

NQF 0022

156

Use of High-Risk Medications in the Elderly

PQRS 0318

NQF 0101

139

Falls: Screening for Future Fall Risk

TBD

NQF 1365

177

Child and Adolescent Major Depressive Disorder: Suicide Risk Assessment

TBD

N/A

179

ADE Prevention and Monitoring: Warfarin Time in Therapeutic Range


Sandra Pogones, MPA, CPHQ, CHTS-IM

Program Manager Physician Services

Primaris

200 N. Keene St., Suite 101

Columbia, MO 65201

1-800-735-6776 (General Office)

(573)-673-4531 (Cell)

(573) 777-9062 (Fax)

[email protected]