2012Healthinsightphysician Office Quality Award Application

2012HealthInsightPhysician Office Quality Award Application

Please complete this application to be considered for the 2012HealthInsightPhysician OfficeQuality Award. If completing on-line, the tab keymay be used to navigate to the next field.

Practice Name*: / Clinic NPI:
Address:
City, State, Zip:
Practice Type: / Internal Medicine / Family Practice / Pediatrics / OB/GYN / Geriatrics
Other: / Number of Physicians:
Name of Practice Primary Contact:
Title:
Phone: / Email Address:
For practices with multiple sites, please complete demographic information for each site using the addendum at the end of the application as well as quality measure information for each site.
If a multi-site practice is selected as an award recipient, HealthInsight will cover the cost of the plaque for the first site. If additional plaques are requested, the practice must incur those costs (approximately $113.50 per plaque).
* Please write the clinic’s name as the clinic would like it to appear on the award in the event that the clinic is a recipient.
If my practice is selected as a recipient of the 2012HealthInsight Quality Award, I authorize HealthInsight to publicly announce this via press releases, articles, and website announcements.
Signature: / Date:

In order to demonstrate eligibility for the award, please respond to the following questions:

Criterion 1 – Technology
Please select at least TWO of the technologies currently used in the practice and provide the vendor name and the version of the technology used, and the date the clinic first began using the system.
Electronic Health Record (EHR)/ Electronic Medical Record (EMR) System
Vendor:
Version:
Date the clinic first began using this technology:
ePrescribing System
Vendor:
Version:
Date the clinic first began using this technology:
Electronic Patient Portal
Vendor:
Version:
Date the clinic first began using this technology:
Health Information Exchange(HIE) -- (e.g. Virtual Health Record (VHR))
Vendor:
Version:
Date the clinic first began using this technology:
Other Health Information Technology (provide details)
Vendor:
Version:
Date the clinic first began using this technology:
Criterion 2 – Population Care Management

Please select at least ONEof the care management methods used in the practice.

EHR-Based Practices (for this method, please select at least THREE of the following – check all that apply)
Automated Reminder System
Prompts and Alerts
Health Maintenance Template
Chronic Disease Template
Drug-Drug, Drug-Allergy Interaction Checking
Drug-Lab Checking
Chronic Disease Registry or Patient List
Attainment of Medical Home Certification
Member of designated Accountable Care Organization Certification (ACO)
Attainment of Stage 1 Meaningful Use Criteria
Case Managers/Care Management Teams
2. For the care management methods selected above, please briefly describe how the clinic uses each method and with what frequency.
3. Please append supporting documents necessary to demonstrate how the practice meets the criterion for the method described in Step 2.

If an EHR-based method, provide a screen shot of electronic mechanisms used.
For other care management methods, please provide a screen shot or, alternatively, a copy of any policy, procedure, certificate, or other written document (e.g. diabetes flow sheet) that demonstrates the nature of the practice innovation.

Criterion 3 – Data Reporting Quality Initiatives
Please select at least ONE data reporting quality initiatives the clinic is currently involved in and provide documentation to demonstrate participation.
Physician Quality Reporting Initiative (PQRS) – Formerly PQRI
Regional Extension Center Participation*
IC3 Beacon Community Participation*
Utah Pediatric Partnership to Improve Healthcare Quality (UPIQ)
The Guideline Advantage™ Program
HealthInsight Learning and Action Network*
AFIX Quality Improvement Program (USIS)
Reach Out and Read (ROR - Pediatric)
Personalized Primary Care (Intermountain)
Payer Quality Improvement Project
Other Recognized Physician Office Data Reporting Initiative (please provide details)
- Name of initiative:
- Brief Description:
- Website or other documentation of the initiative:
* HealthInsightcan verify clinic participation in the Regional Extension Center, IC3 Beacon Community, and HealthInsight Learning and Action Networks reporting initiatives.
Criterion 4 – Quality Measures
Please report at least FOUR for Family Practice/Internal Medicine, TWO for OB/GYN, TWO for Pediatrics, and ONE for Opthalmology.
For this criterion, please complete the following:

Select the clinical quality measures used to meet the threshold measurement.
Enter the clinic’s current level of performance (rate).
Provide the number of patients used in the denominator for each outcome reported on, as well as the timeframe used for the report (i.e. mm/dd/yyyy - mm/dd/yyyy).
Attach documentation to confirm the clinic’s clinical outcome performance. Any of the following formats is acceptable: a report generated from an EHR, a third-party quality report, or claims-based data report.

Annual Diabetes Measures
HbA1c Test Target Threshold = 91% *H, P
HbA1c Test rate: Denominator: Timeframe:
HbA1c Poor Control, A1c9%Target Threshold =23% (lower is better) *M,P
HbA1c Poor Control, A1c > 9% Rate: Denominator: Timeframe:
LDL Control, <100 mg/dLTarget Threshold= 46% *P
LDL Control, < 100 mg/dLRate: Denominator: Timeframe:
LDLTest Target Threshold = 87% *H,P
LDLTest Rate: Denominator: Timeframe:
Nephropathy TestTarget Threshold = 85% *H, M, P
Nephropathy Test Rate: Denominator: Timeframe:
Dilated Eye ExamTarget Threshold = 66% *M, P
Dilated Eye ExamRate: Denominator: Timeframe:
Other
Dilated Eye ExamRate: Denominator: Timeframe:
Cardiac Measures
Blood Pressure Control, <140/90 mmHgTarget Threshold = 65% *M, P
Blood Pressure Control, < 140/90mmHg Rate: Denominator:
Timeframe:
LDLControl, < 100 mg/dL Target Threshold = 59% *M, P
LDL Control, < 100mg/dLRate: Denominator: Timeframe:
Smoking CessationTarget Threshold = 80% *M, P
Smoking CessationRate: Denominator: Timeframe:
Remember to attach appropriate documentation.
Aspirin for Ischemic Heart Disease Target Threshold = 47% *M, P
AspirinRate: Denominator: Timeframe:
Other
Dilated Eye ExamRate: Denominator: Timeframe:
Cancer Screenings
MammogramTarget Threshold = 76% *H, M, P
MammogramRate: Denominator: Timeframe:
Cervical Cancer ScreeningTarget Threshold = 79% *P
Cervical Cancer Screening Rate: Denominator: Timeframe:
Colorectal Cancer ScreeningTarget Threshold = 63% *M, P
Colorectal Cancer ScreeningRate: Denominator: Timeframe:
Other
Dilated Eye ExamRate: Denominator: Timeframe:
Immunizations
Influenza Target Threshold = 56% *P
Influenza Rate: Denominator: Timeframe:
PneumoniaTarget Threshold = 78% *M, P
PneumoniaRate: Denominator: Timeframe:
Other
Dilated Eye ExamRate: Denominator: Timeframe:
OB/GYN
See Cancer Screenings
Chlamydia ScreeningTarget Threshold = 48% *M, P
Chlamydia Screening Rate: Denominator: Timeframe:
Other
Dilated Eye ExamRate: Denominator: Timeframe:
Ophthalmology Measure
Glaucoma Screening for Older Adults Target Threshold = 75% *P
Glaucoma Screening for Older AdultsRate: Denominator: Timeframe:
Remember to attach appropriate documentation.
Other
Dilated Eye ExamRate: Denominator: Timeframe:
Pediatrics
Childhood ImmunizationTarget Threshold = 85% *M, P
Childhood Immunization Rate: Denominator: Timeframe:
Lead Screening Target Threshold = 66%
Lead Screening Rate: Denominator: Timeframe:
Body Mass Index Target Threshold = 52% *M, P
Body Mass Index Rate: Denominator: Timeframe:
Adolescent Well CareTarget Threshold = 47%
Adolescent Well Care Rate: Denominator: Timeframe:
Well Checks by 15 Months TargetThreshold = 19% *H
Well Checks by 15 Months Rate: Denominator: Timeframe:
Adolescent Immunizations by Age 13 Target Threshold = 76%
Adolescent Immunizations by Age 13 Rate: Denominator: Timeframe:
Other
Dilated Eye ExamRate: Denominator: Timeframe:
Utilization
Imaging Studies for Low Back Pain Target Threshold = 78% *M, P
Imaging Studies for Low Back Pain Rate: Denominator: Timeframe:
Other
Dilated Eye ExamRate: Denominator: Timeframe:
*See Appendix A For Examples:
H = HB128, M = Meaningful Use, P = PQRS
Remember to attach appropriate documentation.

Feedback

Feedback is welcome on the application process or suggestions for measures or technologies to incorporate in the future. Please provide them here:

Addendum for Multiple Site Practices

Practice Name*: / Clinic NPI:
Address:
City, State, Zip:
Practice Type: / Internal Medicine / Family Practice / Pediatrics / OB/GYN / Geriatrics
Other: / Number of Physicians:
Name of Practice Primary Contact:
Title:
Phone: / Email Address:
Practice Name*: / Clinic NPI:
Address:
City, State, Zip:
Practice Type: / Internal Medicine / Family Practice / Pediatrics / OB/GYN / Geriatrics
Other: / Number of Physicians:
Name of Practice Primary Contact:
Title:
Phone: / Email Address:
Practice Name*: / Clinic NPI:
Address:
City, State, Zip:
Practice Type: / Internal Medicine / Family Practice / Pediatrics / OB/GYN / Geriatrics
Other: / Number of Physicians:
Name of Practice Primary Contact:
Title:
Phone: / Email Address:

* Please write the clinic’s name as the practice would like it to appear on the award in the event that the clinic is a recipient.

2012HealthInsight Physician Office Quality Award Application 1