Objective 7 - Health Information Exchange

Objective 7 - Health Information Exchange

Overview

Suggested Strategy

Can I be exempted?

Unpacking Measure 1

Definition of the metric

FAQ

Helper SQL

Sample results

Unpacking Measure 2

Definition of the metric

FAQ

Helper SQL

Sample results

Unpacking Measure 3

Definition of the metric

FAQ

Helper SQL

Sample results

Objective 7 - Health Information Exchange

Overview

Objective 7, “Health Information Exchange,” is a group of three submetrics.  Think of them as the Referrals Group.

  1. Measure 1:  Referrals sent electronically (>50% to pass)
  2. Measure 2:  Receipt of electronic referral response (>40% to pass)
  3. Measure 3:  Clinical reconciliation of inbound care transitions (>80% to pass)

While you must report a number for all three measures, you only need to pass two of them.  

For all three measures:

Suggested Strategy

Pass Measure 3, then:

Can I be exempted?

Unpacking Measure 1

Definition of the metric

Denominator:  Every Referral created during the attestation period sent from the attesting doctor to a specialist.

Numerator: Referrals in the denominator for which an electronic referral was sent and either:


FAQ

What referrals count in the denominator for Measure 1?

A Referral (must be type “Referral to a specialist”) created during the attestation period (here 10/17/19 is within the 90 day attestation period selected by the attesting doctor) sent from the attesting doctor (here, Wayne Best, MD) to a specialist.

How do I increment the numerator for Measure 1 using the automatic/DIRECT method?

First, be sure the Include Summary box is checked, then click the Send button:

You will be redirected to the Message screen.  If your specialist has a DIRECT address in his/er entry in the Address Book, his/her name will populate.  If you successfully created a CDA, it will be attached to the Message.  

If you click Send, and you see this message:

...the numerator will automatically increment.

How do I increment the numerator for Measure 1 using the manual attestation method?

First, you will have to send a referral message to the specialist using an electronic method.  This might be by sending the referral information to an HIE or RHIO the specialist participates with.  Alternatively, this might involve sending the referral using a standard email address, but using an encryption feature for HIPAA compliance.  Sending via fax or mail do not count for the purposes of this metric.

Once you have sent the referral electronically, you must attest that the specialist/recipient has received it.  This will generally involve calling the recipient’s office and confirming that they can decrypt/read what you sent.  Once you have done so, attest to this by clicking the “Specialist confirms receipt of this referral” box:

This will provide an alternate method for incrementing your numerator.

When you send a message outside of OP, OP will not have any record of how you sent this message.  Therefore, we strongly suggest that for every submission that you manually attest to, keep a record of how it was sent (e.g. method and date in the Internal Notes section of the referral, copies of the referral CC’d to yourself and stored in a special folder in your email, etc.)  We suspect that practices who send no DIRECT messages but attest to a high level of electronic referral submissions will be subject to audit.

Does the physician have to be the one sending the DIRECT message?

No.  For example, it is perfectly acceptable for the referral coordinator at your office to send the referral and DIRECT message; it does not have to be the attesting physician.  The attesting physician will still get credit.

I’m not sure whether I saw the “Message Successfully Sent” popup.  Should I check the “Specialist confirms receipt of this referral” to be sure?

No.  The helper SQL for this metric will show you whether the message was sent by DIRECT successfully or not.  If it incremented automatically, leave the checkbox alone. Clicking the “Specialist confirms receipt of this referral” does not increment your numerator further and only confuses the picture whether you intended to use DIRECT or an alternate method.

Why am I getting “The selected recipient does not have a Direct email” message?

Sometimes, after clicking Send in the Referral screen, you may get a popup:

There are at least three possibilities:

  1. The Address Book entry you have selected does not have a DIRECT address entered in it.
  2. There are multiple Address Book entries for this specialist; one has a DIRECT address and one does not, and you selected the one that does not.
  3. When the name of the specialist was entered, it was simply typed into the Referred to field (left red boxed field) or linked from the Coordination of Care button (right red boxed button.)  For a DIRECT address to reliably populate, the specialist must be looked up in and linked to from the Address Book entry (green boxed “Rolodex” button.)

How can I tell which of my Referrals are, or are not, linked to an Address Book entry?  

See the Show me My Referrals SQL from “Step 2: Finding the Specialists You’re Missing” from the message Taxonomy Test. 

How do I add a DIRECT address to a specialist’s Address Book entry?

See “How do I attach a DIRECT address to an Addressbook entry?” in the message DIRECT Addresses: Start Now! Part 1 of 2.

Why don’t I see the “Specialist confirms receipt of this referral” check box?

This feature is present only in OP 20 and later editions.

Why am I getting an error message when running the Helper SQL?

Some of the fields are only present in OP 20 and later editions.

What am I supposed to enter for Provider in the Helper SQL?

This is the OP provider’s ID number (which you can see on the schedule above their column.)  Names or initials will ont work.

Helper SQL

with msg_log as

( select referral_number, link_id, m.msg_id, text, date1 as msg_date, addr_id as msg_from, pat_id as patno, subject, recipient_op_id, delivery_status, ext_message_id from esmg_org_msg m

left outer join (

select delivery_id, msg_id, addr_id as recipient_op_id, delivery_status, ext_message_id  from esmg_delivery where is_external = 1 and ext_message_id is not null and ext_message_id <> '' ) d on d.msg_id = m.msg_id

inner join (select enc_id as referral_number, addr_id as link_id, attach_date, attach_id from enc_attach where enc_table = 'REFERALLETTER' and attach_table = 'Message' and attach_date between :Start_date and :end_date +1 ) a on a.attach_id = m.msg_id

where m.parent_id is null and m.is_external = 0 and m.pat_id is not null

and d.delivery_id is not null

)

select

case

when direct_email is not null and ext_message_id is not null and msg_id is not null and   recipient_op_id = recipient_id and manual_override = 1 then 'pass (sent electronically & manual override)'

when direct_email is not null and ext_message_id is not null and msg_id is not null and  recipient_op_id =  recipient_id then 'pass (sent electronically)'

when manual_override = 1 then 'pass for manual override'

when (direct_email is null or direct_email = '') then 'fail: no direct email for recipient'

when ( msg_id is null ) then 'fail: no direct message created'

when ext_message_id is null then 'fail: direct message not sent'

when recipient_op_id <> recipient_id then 'fail: sent successfully, but not to the referral recipient'

else 'undetermined'

end as det,

 b.*  from (

select letterno as ref_referral_number, rf.patno as ppatno, date1 as ref_date, rf.p_addr_id, custom1, refmd, ab.addr_id as recipient_id, ab.direct_email, receipt_confirmed as manual_override,

msg_log.*

  from referalletter rf

inner join register on register.patno = rf.patno

left outer join addressbook ab on ab.addr_id = rf.refmd_addr_id

left outer join msg_log on msg_log.referral_number = rf.letterno

where (rf.custom1 in ('REFERRAL')) and (rf.date1 between :start_date and :end_date ) and rf.P_addr_id = :provider

) b

order by ppatno

Sample results

In this example, there are 22 rows (purple box, bottom left), so this provider’s denominator will be 22.  There are 11 pass rows (green) and 11 fail rows (red), for a total performance of 50% (11/22).  Fail rows give more specific reasons as to the failure: no direct email in the Addressbook, no direct message created, a direct message was created but not sent to the same individual as the referral recipient, etc.

Unpacking Measure 2

Definition of the metric

Denominator: There are three distinct types of patient-episodes which collectively form the denominator:

  1. Every new patient seen during the attestation period whose assigned PCP is the attesting clinician
  2. Every Response to a referral created during the period, where the Responding Provider was the attesting clinician
  3. Every Tracking Entry/Care Transition created during the period, where the Receiving Provider was the attesting clinician, and the reason for care transition did not include the words “new patient”

Numerator: For each patient-episode in the denominator, an electronic CDA was imported into OP and attached to the appropriate Response or Tracking Entry.

  1. For new patients, a Tracking Entry is created, and the reason for care transition includes the phrase “new patient” (not case sensitive), and a CDA from the previous PCP (or possibly newborn stay, in the case of an infant/NICU grad) is attached to the Tracking Entry
  2. For other Responses and Tracking Entries (denominator b) and c) above), the CDA appropriate is linked to that Response or Tracking Entry
  3. OR:  For any CDA which you request, but the specialist tells you they cannot/will not send the summary electronically, you may manually exempt that patient-episode by clicking the “Electronic referral response requested from specialist” checkbox

FAQ

Please define “new patient” for the purposes of this metric.

A new patient is a patient for whom a new patient visit code (9920x or 9938x) was billed for a date of service during the attestation period.  The code must have been assigned through the encounter or well note, i.e. before the note was finalized, rather than directly as a claim after the note was archived.  

Whose responsibility are new patients?

The metric assigns responsibility for getting new patient CDAs to the patient’s PCP, which is not necessarily the same as the clinician who conducted the new patient visit.  This has the benefit of excusing of covering “one-off” cross-cover visits for another practice.  It also is in keeping with the reality that incoming CDAs rarely come on the same day as a new patient is seen.

How do I import a DIRECT CDA into a child’s chart?

Coming soon...

How does OP know whether a tracking entry is supposed to match up with a patient being a new patient vs a transition of care from somewhere else?

Patients who have a new patient visit CPT Code should have one tracking entry in which the words “new patient” (not case sensitive) appear in the Reason for care transition field.  If the phrase “new patient” does not appear, OP will assume it will be for another purpose.   It is possible for a new patient to have other Tracking Entries.  For example, a newborn establishes care with the practice after nursery discharge, and two weeks later visits the ER for a brief resolved unexplained event (BRUE).  OP would expect to see two tracking entries: one from the newborn nursery containing the phrase “new patient”, and one from the hospital ER, containing some other phrase.  Both, either, or neither might have a CDA attached.

How do I link a CDA to a Response or Tracking Entry?

I’ve followed the steps, but I’m not getting credit for my referral Response with attachment.

This screenshot illustrates common pitfalls in meeting this metric.  There are four examples given here: a return to school note of record type Letter (pale blue); a Response to a referral to Dr. Acra (pale yellow); a Referral and attached Response to Cumberland Medical Center (pink), and a Referral and attached Response to Dr. Simpson (green.)  Only Dr. Simpson’s example will get credit:

 

I’ve linked the Response and CDA correctly, but I’m still not getting credit.

The document that is linked to the CDA must be an XML/CDA type document.  

Other document types (JPG, PDF, etc) did not necessarily originate as electronic (they may have been scanned from a fax, for example) and do not meet the metric’s qualifications.  If the specialist was unable/unwilling to send a CDA response, you may check the Electronic referral response requested from specialist box, which will exempt that particular Referral/Response pair.

Why don’t I see the  “Electronic referral response requested from specialist” check box?

This feature is present only in OP 20 and later editions.

Why am I getting an error message when running the Helper SQL?

Some of the fields are only present in OP 20 and later editions.

Helper SQL

with new_pts as (

select 'new patient' as reason, patno, pl.date1,   pl.cptcode  from procedure_list pl

inner join register on register.patno = pl.patno

where  (pl.cptcode like '9920%'  or pl.cptcode like '9938%')

and pl.date1 between :Start_date and :end_Date

and register.addr_id = :provider

), resp_track as

(

select

case when rf.custom1 = 'RESPONSE' then  'referral response' when rf.custom1 = 'TRACKING ENTRY' then 'tracking entry (not new pt' else 'no reason' end as reason,  

patno, date1,

case when rf.custom1 = 'RESPONSE' then  letterno when rf.custom1 = 'TRACKING ENTRY' then letterno else 'unknown' end as  ref_num,

 refmd as outside_entity,   rf.ELECTRONIC_REQUEST_RESPONSE , 'n/a' as cptcode,  rf.med_reconciliation_status from referalletter rf

inner join register on register.patno = rf.patno

where ( rf.custom1 = 'RESPONSE' OR (  rf.custom1 = 'TRACKING ENTRY' and   lower(reason) not like '%new patient%' ))

and (rf.date1 between :start_Date and :end_Date ) and rf.p_addr_id =:provider and status = 'COMPLETE'

order by patno),

tracking_new as

(

select   patno, ref_num, outside_entity,  pl.date1, ELECTRONIC_REQUEST_RESPONSE, med_reconciliation_status from procedure_list pl

inner join register on register.patno = pl.patno

inner join (select patno, ELECTRONIC_REQUEST_RESPONSE, letterno,  refmd as outside_entity, letterno as ref_num, med_reconciliation_status from referalletter where status='COMPLETE' and custom1 = 'TRACKING ENTRY' and date1 between :START_DATE AND :END_DATE and lower(reason) like '%new patient%') rl on rl.patno = pl.PATNO

where  (pl.cptcode like '9920%'  or pl.cptcode like '9938%')

and pl.date1 between :Start_date and :end_Date

and register.addr_id = :provider

)

select

case

when electronic_request_response = 1 then 'EXCLUSION'

when attach_table  is null then 'fail: no attachment'

when file_type <> 'CDA' then 'fail: attachment, but not a CDA'  

when file_type = 'CDA' and med_reconciliation_status not in (1,2) then 'pass: CDA attached/incorporated'

when file_type = 'CDA' and med_reconciliation_status  in (1,2) then 'pass with reconcilation'

 else 'undetermined' end as det,

a.*, cda.*  from

(

select new_pts.reason, new_pts.patno, new_pts.date1, new_pts.cptcode, tracking_new.ref_num, outside_entity, tracking_new.ELECTRONIC_REQUEST_RESPONSE, tracking_new.med_reconciliation_status from new_pts

left outer join tracking_new on new_pts.patno= tracking_new.patno

union

select reason, patno, date1, cptcode, ref_num, outside_entity, electronic_request_response, med_reconciliation_status from resp_track

) a

left outer join (

   select enc_id, attach_table, attach_id, file_type from enc_attach inner join ( select referenceid, file_type from docimage_metadata) docs on enc_attach.attach_id =docs.referenceid

  where enc_table = 'REFERALLETTER' and attach_date between :STart_date and :end_date +1)

cda on cda.enc_id = a.ref_num

order by reason, patno

Sample results

In this example, there are 18 rows (purple box, bottom left), so this provider’s denominator will be 18.  There are 10 pass rows (green) and 8 fail rows (red), for a total performance of 55.6% (10/18).  The Reason field gives the justification for why an episode appears - a new patient, a Response to a referral, or a Tracking Entry.   Fail rows give more specific reasons as to the failure: no CDA was attached to the Response/Tracking entry, an attachment was linked but it was not a CDA.  Exclusions (if the “Electronic referral response requested from specialist” is checked) will be shown as “EXCLUSION.”

Unpacking Measure 3

Definition of the metric

Denominator:  Every new patient seen during the attestation period PLUS every Response to a referral created during the attestation period period PLUS every Tracking Entry not associated with a new patient created during the attestation period

[This is the same denominator as Measure 2.]

Numerator: For each patient-episode in the denominator, a member of the care team attests to reconciliation of medications, problem list, and allergies (or attests that such reconciliation was not required) along with the clinical staff member performing the reconciliation, and the date on which the reconciliation was performed.

FAQ

Why are my new patients not meeting the metric?

You must create a Tracking Entry with the phrase “new patient” in the Reason for Care Transition field so that you have a place to attest to clinical reconciliation for new patients.

Isn’t this just the same as the old Medication Reconciliation Measure?

They are similar.  Meaningful Use Stage 3 requires providers to attest not only to medication reconciliation, but that the problem list and allergy list were also reconciled.  OP 20 now prompts for the more general “Reconciliation” as opposed to the OP 19 and prior more limited scope “Medication reconciliation.”

Why does my screen still say “Med reconciliation” and not “Reconciliation?

The language that says “Reconciliation” is present only in OP 20 and later editions.

Helper SQL

with new_pts as (

select 'new patient' as reason, patno, pl.date1,   pl.cptcode from procedure_list pl

inner join register on register.patno = pl.patno

where  (pl.cptcode like '9920%'  or pl.cptcode like '9938%')

and pl.date1 between :Start_date and :end_Date

and register.addr_id = :provider

), resp_track as

(

select

case when rf.custom1 = 'RESPONSE' then  'referral response' when rf.custom1 = 'TRACKING ENTRY' then 'tracking entry (not new patient)' else 'unknown reason' end as reason,

 patno, date1, 'n/a' as cptcode,  letterno as response_number,   rf.med_reconciliation_status from referalletter rf

inner join register on register.patno = rf.patno

where (rf.custom1 = 'RESPONSE' or (   rf.custom1 = 'TRACKING ENTRY'  and  lower(reason) not like '%new patient%'  ) )

and (rf.date1 between :start_Date and :end_Date ) and rf.p_addr_id =:provider and status = 'COMPLETE'

order by patno)

,tracking_new as

(

select   patno,  pl.date1,  letterno as response_number, med_reconciliation_status from procedure_list pl

inner join register on register.patno = pl.patno

inner join (select patno, med_reconciliation_status, letterno from referalletter where status='COMPLETE' and custom1 = 'TRACKING ENTRY' and date1 between :START_DATE AND :END_DATE and lower(reason) like '%new patient%') rl on rl.patno = pl.PATNO

where  (pl.cptcode like '9920%'  or pl.cptcode like '9938%')

and pl.date1 between :Start_date and :end_Date

and register.addr_id = :provider

)

select case when med_reconciliation_status in (1,2) then 'pass' else 'fail' end as metric,

 a.* from

(

select new_pts.*, tracking_new.response_number, tracking_new.med_reconciliation_status from new_pts

left outer join tracking_new on new_pts.patno= tracking_new.patno

union

select * from resp_track

) a

Sample results

In this example, there are 18 rows (purple box, bottom left), so this provider’s denominator will be 18.  There are 10 pass rows (green) and 8 fail rows (red), for a total performance of 55.6% (10/18).  The Reason field gives the justification for why an episode appears - a new patient, a Response to a referral, or a Tracking Entry.

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