chcanys nys hccn ecw webinar 6 uds pdfs/hit/hcnn... · perinatal services for the prenatal access...

CHCANYS NYS HCCNeCW Webinar 6

UDS

December 11, 2014

Stephanie Rose, Project Director

Desiree Railine, HIT Implementation Specialist

Agenda

eCW UDS Updates

Security Risk Assessment

Provider Tracking tool

MU Audit Preparedness

MEIPASS Attestations

12/11/2014 HEALTH CENTER NETWORK OF NEW YORK 2

eCW UDS 2014 Updates

12/11/2014 3HEALTH CENTER NETWORK OF NEW YORK

UDS Refresher•Tool used to report a core set of information to HRSA on the health center operation and performance

•Reporting requirement for HRSA Primary Care Program grantees• Community Health Center• Migrant Health Center• Health Care for the Homeless• Public Housing Primary Care• Other Section 330 Grantees

•Submitted Annually by 2/15 of each year12/11/2014 HEALTH CENTER NETWORK OF NEW YORK 4

CY 2014 Changes – HRSA PAL•Table 4 - Public housing reported for all grantees

•Table - 6A First Diagnosis of HIV

•Table 6B and 7 – Prenatal and perinatal services reported for all health center patients

•Table 6B – Quality of Care Indicators• Removed No Prenatal care provided• Combined tobacco screening and cessation• Added new HIV cases with timely follow up• Added clinical depression screening and follow up

•Table 7 – Revised Diabetes Control to remove A1C <7

•EHR Certification and PCMH Recognition


Table 3B – eCW V10 Enhancement

•Version 10 has the ability to select more than one race from the race list

•eCW will report “more than one race” if two or more boxes are checked.


Table 3B


Table 4: Patient Characteristics•eCW will use the Structured “Misc Info” from Demographics to report the new Public Housing requirement for all grantees

•Be sure that you have this in your structured data and your staff are trained to complete it for all patients.


Table 4


Table 4 – Poverty Level eCW Enhancement

•eCW will look at the most recent poverty level within 365 days of the most recent visit.

•Based on the Dates entered on the Sliding Fee Income Details.


Table 4 – Encounter Based Zip Codes

•eCW Uses Primary Insurance and Zip Code from Demographics for encounter-based reports


Table 6A – Diagnoses and Services

•New category for Newly Diagnosed HIV patients• Currently there is no easy way to report on patients that

received their first ever HIV diagnosis (not just at your center)

• eCW will look at the Assessment Notes Onset Date field• This will likely take manual effort to review possible

patients to determine how many are newly diagnosed


Workflow Change


When adding the HIV Initial Assessment, providers will need to click in the notes field and add the Onset Date.

Table 6B – New HIV Cases with Timely Follow-up

•Use the patients newly diagnosed HIV patients from Table 6A

•Determine if they received follow up care within 90 days of the diagnosis• Referral required• Appointment date must be less than 90 days from onset

date• HIV Diagnoses must be included on the referral


Table 6B – New HIV Cases with Timely Follow-up


Table 6B Section B: Prenatal CareAll health centers now are required to report prenatal and perinatal services for the prenatal access to care and low birth weight measures in Table 6B and Table 7, for all health center patients regardless of whether they receive services in the health center or are referred elsewhere.

•eCW OB Flowsheet Use• Uses the LMP to calculate the trimester the patient began

receiving services• If LMP is not entered, they will use the EDD

•Review the exception reports


Table 6B – Prenatal Care


Table 7


Table 6B Clinical Depression Screening

•Clinical Depression screening of medical patients age 12+ during the reporting period • eCW PHQ2 Smart Form Used• eCW PHQ9 identifies Minimal, Mild, Moderate or Severe

Depression• Determine what level of depression that needs follow up for the

practice• If screened positive, the patient must have a follow-up

plan documented• Document in Structured Data/HPI/Depression

Screening/Intervention


Community Mapping Requirements•PHQ2 Smart Form

•PHQ9 Smart Form

•HPI Depression Screening/Intervention• Follow Up for Depression• Depression Screening Findings


Table 6B Clinical Depression Screening


Tobacco Use Screening and Intervention•Combined tobacco use screening and cessation into one measure.

•Patients Screened and Intervened as appropriate (Compliant)• Patients screened for tobacco use that were not tobacco users and;• Patient screened for tobacco use and identified as tobacco users who

received cessation intervention


Same eCW Documentation

Record the screening via

Smart Form drop down field;

OR

Social History Tobacco Use Smoking ◦ Are you a:◦ Additional Findings: Tobacco User◦ Additional Findings: Tobacco Non-User



eCW Tobacco Use Smart Form

Exceptions

Patient has to have a medical reason excepted.

Information has be recorded as structured dataParent Question:Social History Tobacco Use Screening Not Performed Q:

Reason; A: Medical reason or limited life expectancyChild Questions:Q: Type of medical reason; A: various optionsQ: Details; A: various options


Same eCW Counseling Documentation

If the patient has been identified as a tobacco user, documentation of counseling intervention has to be recorded as structured data.

*Preventive Medicine Counseling


* A complete listing of all of the questions can be found on the My eClinicalWorks portal under the Meaningful Use Stage 2 documentation.

MappingStructured data must be mapped to community items in the Mapper Window. To access: Community Mappings Structured Data


Use the filters to drill down to the items

Choose/ highlight item

Choose/ highlight item

Click the Map button.Items will them turn blue.

Table 7 – Diabetes by Race and Ethnicity•Eliminated the HbA1c <7 category for reporting

•No process changes required

•No change in EBO Reporting to select HbA1C labs and attributes from last year


eCW Compliance Reports Available

•eCW 2014 EBO reports will include detail reports to show is or is not compliant for each measure so you can review the items and take action.


Table 5 and 6B Mapping Validation •eCW EBO UDS reports will View all of the mapped values in one place


Exception Reports

•Be sure to review the exception reports to validate and make edits as necessary• Patients excluded from Adult Weight Screening• Incorrect onset date in HIV Diagnosis• Resource Provider Utilization• OB Flowsheets – V10 allows you to unlock and correct


Getting Started

•Review the training documentation/webinars on my.eclinicalworks.com

•Open a support ticket to have the 2014 UDS Package added to your system


UDS Reports•UDS moved from the Report Console to EBO in 2013• UDS• UDS SQL (if you use MS SQL instead of MySQL database)

•Decide if you are reporting encounters by claims or encounters• Review documentation to determine which method you

want to use and use the same method for all reports• Complete mapping


CPCI UDS Report Option

CPCI contains 8 tables required for the federal Uniform Data System (UDS) report


Security Risk Assessment


Risk Assessment

Stage 1

Conduct or review a security risk analysis per 45 CFR 164.308 (a)(1) and implement security updates as necessary and correct identified security deficiencies as part of its Risk Management

Stage 2

adds “including addressing the encryption/security of data at rest”


Risk Assessment Timeframe

Clarified by CMS that you need to complete or review this each year during the reporting year.


Resources

•Health IT.Gov Risk Assessment Tool

•Health IT.Gov• Regulatory and Guidance• Education and Training Material• Brochures• Videos


http://www.healthit.gov/providers-professionals/security-risk-assessment-tool

http://www.healthit.gov/providers-professionals/ehr-privacy-security/resources

Provider Tracking Tool


The Importance of Tracking

Attest for Meaningful Use on an individual provider level

Providers will likely be at different stages and participation years

It is important to know where each providers is in the incentive program to ensure they meet the requirements and can attest as soon as possible



Tracking Tool

Provider Credential Worksheet

Meaningful Use Stage/Participation Year Tracking Worksheet

Budget Worksheet

CHCANYS Website Link to Tracking Tool

http://www.chcanys.org/index.php?src=gendocs&ref=HCNNY_Materials&category=NYS_HCCN

Audit Preparedness


Audit OverviewAll providers/practices attesting for the EHR incentive should retain ALL relevant supporting documentation

States and their contractors will perform audits for the Medicaid incentive

Documentation will be used to validate your attestation


Pre-Payment ChecksMedicaid will perform numerous pre-payment checks prior to paying the incentive◦ FQHC Calculation – per provider◦ Medicaid or Needy Calculation ◦ CMS data◦ ETIN linkage◦ Medicaid FFS provider


Post Payment AuditIf a provider is found to not be eligible for the EHR incentive payment based on the audit, the payment will be recouped


CMS Guidancewww.cms.gov (Regulations and Guidance/ Legislation/ EHR Incentive Programs/ Educational Materials/ Audit Overview Fact Sheet)

www.cms.gov (Regulations and Guidance/ Legislation/ EHR Incentive Programs/ Educational Materials/ Supporting Documentation Audits)


http://www.cms.gov/

http://www.cms.gov/

Timeframe for Audit ResponsePractice/provider has 10 days to provide supporting documentation

Delays in providing documentation raise audit flags


Meaningful Use ReportsBe sure you understand where your Meaningful Use reports are pulling data from in your CEHR

Be sure you understand the workflow

Have policies/procedures that are accessible

Retain paper/electronic reports for each provider


Meaningful Use ReportsMust include:◦ Numerators & denominators for Core, Menu & Clinical

Quality measures◦ Time period the report covers (within the Reporting

Period)◦ Evidence to support that it was generated for the Eligible

Provider (e.g. NPI, provider name)


Attestation Objectives Maintain screenshots (paper/electronic) dated during the

Reporting Period for:

◦ Drug-Drug and Drug-Allergy◦ Drug Formulary◦ CDSS◦ Immunization test or ongoing submission

(Pass/Fail/Success Message)◦ Syndromic Surveillance test or ongoing submission

(Pass/Fail/Success Message)


Drug-Drug/Drug Allergy Screen Shot


Use a test patient, add an allergy and then prescribe what they are allergic to. You can also prescribe another drug that interacts with it. Option 2, find a real patient with the interaction.

Drug Formulary Screen Shot


CDSS Screen Shot


MEIPASS


MAQ Dashboard Reports

You can download the 8 comma delimited files (CSV) from eCW for the 90 day period for each provider through the 90 day reports or MAQ on demandCoreMenu6 CQM files


Where to get help?


eMedNY Webinars◦ https://www.emedny.org/meipass/info/Events.aspx#top

eMedNY Documentation◦ Step by Step data entry◦ FAQs◦ Webinar Slideshttps://www.emedny.org/meipass/ref/index.aspx

https://www.emedny.org/meipass/info/Events.aspx%23top

https://www.emedny.org/meipass/ref/index.aspx

MEIPASS Prerequisites

New providersNeed to know if they attested previously with another

organization and which programDon’t wait to the last minute – it takes time

Existing ProvidersAre they current with Medicaid enrollment and ETIN

https://www.emedny.org/meipass/ep/prereq.aspx


https://www.emedny.org/meipass/ep/prereq.aspx

Prerequisite Process


Medicaid Enrollment

ePaces & MEIPASS

Full Access

ETIN Association or Recertification

CMS Registration

Timing

Submit for Adopt, Implement or Upgrade (AIU) after upgrading to V10 in 2014

Attestation submissions for Payment Year 2014 end on March 31, 2015 Don’t wait until the end of March to start!

Understand the datesMedicaid Eligibility DatesEHR Reporting Year - Payment Year Submission Dates


Medicaid Eligibility Reporting YearThe patient volume reporting period must be derived from any consecutive 90 day period within the calendar year prior to the payment year or preceding 12 month period from the date of the attestation.

Options for 90 day Eligibility PeriodRolling yearCalendar Year


Standard Patient Volume Method

An EP counts the number of patient encounters during the 90-day reporting period that were paidall or in part by Medicaid, and divides that number by the total number of patient encounters over the same period.

Note: You can request the monthly volume list from Medicaid by email to obtain the number they expect, but you can’t use their list for an audit.


Aggregate Patient Volume

Use the overall practice's aggregate patient volume numbers as a proxy for the individual EPs within the practice, but to take advantage of this option all the EPs in the practice must use the group encounter values. (standard or alternative methods)

Note: The EP does not need to work for the practice during this Eligibility Reporting period but you do have to include all encounters.


Do I have to use the Needy Calculation?

FQHC’s have the option to use the Needy calculation but they are not required to use it.

You will need to use it if you are attesting for Physician Assistants that are sole practitioners or if you do not have more than 30% Medicaid patients.

Note: If you use the Needy calculation instead of the standard Medicaid volume, then you have to submit individual provider encounter data for 6 months.


Questions…


NYS-HCCN Ask the Experts Forum


1. If you do not have an account, the link will take you

to the login screen so you can create an account.2. Choose the options for NYS-HCCN members only

3. You will need to wait for an email from the CHCANYS system administrator approving your account before

you’ll be able to log in for the first time.

4. When you get a confirmation, return to this link to log in.

Posting a Question1. Click on a relevant category, e.g., Meaningful Use Data Capture for eClinical Works2. Click the New Topic button in the top right, type a question (message body optional) and

submit the form.a. The question will appear on the list of questions for your selected category.

http://www.chcanys.org/index.php?src=forum

http://www.chcanys.org/index.php?src=forum

We appreciate your feedback! Please take survey using the link belowHTTPS://WWW.SURVEYMONKEY.COM/S/KVKNQMY


https://www.surveymonkey.com/s/KVKNQMY

About HCNNY

HCNNY is a Health Center Controlled Network that provides support to member and non-member health centers utilizing eClinicalWorks.

Please contact Stephanie Rose at [email protected] you are interesting in utilizing our training services or obtaining more information about the benefits of becoming a HCNNY member.


mailto:[email protected]

chcanys nys hccn ecw webinar 6 uds pdfs/hit/hcnn... · perinatal services for the prenatal access...

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