Alright. Great. And I'm gonna share my slides now. So you should be seeing our slide review for the tech the file review management. Sharing. Now we have a AI assistant on our chat. This is something new from Zoom. We'll see how that works. And, but, really, the recording is so that we can post this on our website later. So and I apologize. I've got my my Zoom over here, and my camera's here. So if I'm looking away, I I do apologize. It's just a matter of running multiple screens at once. So thrilled again to be with you. Today, we're gonna be talking about file management. And, really, this is an area that is most important for the care management, aspect, of the PCMH survey. So first, have our disclaimer, that is, oops, that is basically making it clear that this webinar was done as part of our contract with HRSA. But this is, NGQA product, and there are no nonfederal resources that have been approved. So just, being clear what HHS and HRSA have approved, for this. So we just did the welcome and introductions, and then we'll talk a little bit about, actually pulling, files, and providing data on care management. We've got a couple of polling questions. I hope I've done this correctly because this is the first time I've created a poll with multiple questions in it. So we'll see, if that works, well for us in this setting. And then I'll talk a bit about the file review process. And the the fun fact is our file review process has been in place at NCQA, in one form or another since, literally the last century. I have been working here, since nineteen ninety seven, believe it or not, and we have been doing file reviews very similarly for all of our products over the course of that time. So I'm very familiar with the basics of the file review, process itself. So, of course, any questions you have, please feel free to send them through the q and a. And, also, if you have any comments, send those through the chat, which is great. Alright. So, basically, for care management, there are a bunch of of, standards where we are actually looking for evidence that your practice, your health center has been able to provide specific care management services for at least seventy five percent of patients. Now if they're core requirements, you have to respond to them. Of course, if they're elective, you choose to respond to them like Centimeters ten and eleven in the person centered care options, but you still have to reach that seventy five percent threshold. And remember, it's at least seventy five percent. So, technically, seventy five percent doesn't count. It's gotta be seventy five point zero to, you know, infinity with a one. And so that's just something to think about, as you're looking at some of these electives. And there's basically two ways you can do this. You can actually pull electronic reports from your own systems if you are tracking things in a way that allows you to report on it. And remember, we need these data by site. So in general, with one very, rare exception, each location is going to, be expected, each physical location to have at least thirty patients in care management that they can provide data for. So when I talk about sort of pulling the data, I'm gonna talk a little bit about sort of how to assign a patient to a site if they're going to more than one site, in your location. So that's something we will talk a little bit more about. And that's if if you are, pulling either reports or or files, for that patient. And then you can also, combine methods. So it's not required that you only pull reports or you only do a, sort of time consuming file review. You can pick and choose based on the, requirement you're answering, and the component, that you are addressing. So, each criterion has to have one one method or the other. You can't use you know, we we're not using a a hybrid method, like we used to in HEDIS, where you can pull some electronic reports and then fill in data with with records. Here, it's either reports or files depending. So the the seventy five point one percent issue, Tanya asked. So, basically, when we say, I'm sorry. I'm lying to you. That is a horrible thing. I've done a horrible thing. I've mixed up my percentages. So that is my that is my error. I've talked about this so much you would think I would get this correct. This is this is very embarrassing for me. So we say at least seventy five percent. So sorry. The seventy five percent does qualify that. I was mixing up the seventy five percent in care management with the eighty percent requirement in, medication reconciliation. Thank you. I just freaked everybody out. We'll bring it back down. So yeah. So so when we say at least seventy five percent I'm sorry. Seventy five percent does count there. When we say more than eighty percent in our medication reconciliation requirements, that's where you have to have eighty plus zero zero zero out to, you know, infinity with a one. It has to be above eighty percent. So very important. So thank you actually for for asking me to clarify that because I I would hate to leave people with the wrong impression on that one. But yes. So the the at least seventy five percent. And the thing, of course, if you're doing a thirty, med reconciliation is now ninety percent. I apologize. I did not, I have not, absorbed all the twenty twenty six, changes. But same idea. We're looking for better than performance in the, med reconciliation. And and these are some of the very few places where we have specific, operational metrics that we are trying to hit. There's sort of the in quality improvement, there's the general, if you're not at eighty percent, why aren't you working on it kind of question, and and what are you doing to improve? But, in terms of actually getting credit, the care management at seventy five percent and the medication rec at, eighty percent, those kinds of things, and medication list for a at eighty percent are the where we have actually have specific performance, going on. So I'm gonna, launch a poll here, and I'm just gonna stop sharing real quick. Oops. I just paused accidentally. Sorry about that. So I'm going to launch a poll as soon as I can find it. So you should be seeing a poll, with a with three questions. The first is, which items can your practice, actually pull out of electronic reports? And are you seeing the poll or not? I'm just asking at this point. No. No poll. Okay. That's interesting. Okay. Now you should be able to see the poll. Okay. I I I had been testing it, beforehand, so thank you for that. Alright. So the first question is, which of the following care management items can your practice currently provide electronic reports to? And that's a multiple choice option. And then, we'll go on to the second question is, have you ever participated in patient data collection via medical record for PCMH survey? And then if so, how significant was the work? So you should be able to answer. First, the first question is multiple choice, just what can you pull out of your system in terms of the actual electronic data on care management. This really varies widely, and one of the other things that I think, we have learned is that it also can also can often be part of additional packages you have to pay for, in the in your electronic health record. So it may also be that you have the capability to do it, but you don't have it turned on yet, which is, kind of an interesting issue. I've never done this sort of multiple polls before, so hopefully this is working for you. It's something new that we that that I discovered in Zoom. I have not been able this may have been a feature that was, available in the past, but I just know that. Okay. Alright. Just a couple more minutes to answer the questions. Thanks so much. And there was a question about med rec, so I wanna open up the standards to make sure that I'm answering that question correctly. So go to my trusty PCMH standards. Alright. I'm gonna end the poll here. I think we've got everyone, that has, answered, so I'm just sharing the results. Just showing the wide variety of what can be pulled out, and what can't be in electronic electronic records. So I so the question just came up about care plan function in your chart. If it's having problems, are we allowed to compile the components from the chart? Absolutely. You can choose to go in for reports and realize this report is not gonna work for us and then do a chart pull. That's absolutely fine. You can change your mind. You can even do a chart pull and then a report and say, which which data are better? Because you may be doing much better at recording things in one format than another. So but lots of variety in terms of what folks can actually pull out, and that's not surprising. Again, this, care management, I think, is an area that isn't as operationalized, isn't as automated as we would like in a lot of these systems. About sixty percent have actually done a file review, and you can see that those who have done file reviews, it's pretty, significant in terms of the workload. And we recognize that. I mean, it would be great if we could just sort of have a button, sort of NCQA's PCMH button that will put put out all of our data, from, any system that would answer our questions and our requirements. We would love that. No one's actually implemented that yet. And, of course, we don't even have, standardized databases on the back ends of EHRs at this point. So there's a lot of, challenges and, still, I think, functionality that needs to be built and really understood how to to build that. I see that there's a comment, that, one practice will create a reference table to help us remember the different, targets and benchmarks, which is great. I think it's a great idea. And then there's a question about the ninety percent on medication reconciliation saying, is this now annual instead of each visit? So it was never at each visit. There's a lot of of sort of controversy about this. I know this was a big deal also when our our, advisory panel, our our expert panel that helps us put the standards together. When they first looked at this question, there was a big push that that medication reconciliation should be one hundred percent every visit, every single time you talk to the patient. You should be doing med rec, which is a great standard to hold. It is an impossible standard to measure against. And so we originally went for the eighty percent. Now it's ninety percent. But there's basically two questions you have to ask, or there's a question you have to ask about the patient. Has this patient that you're seeing, had a care transition? That is, has they have they seen a provider that's not at your practice and doesn't have access to your medical record? In that case, if the answer is yes, then you should be doing medication reconciliation and determining through any data whether it's a report from the other provider, whether whether it's a, oral report from the patient, whether it's actual records you got from the other provider, a conversation you have with the provider, whatever it was, to document whether anything was prescribed for that patient. If the answer is no, nothing was prescribed by this other provider. So somebody sprained their ankle, went to, the, the emergency room, and they taped it up and gave them ice. No nothing prescribed, so you have done medication reconciliation. They didn't have anything, added to their medication list. So you're, you're you're done. You you know that for a fact. You know they had a transition. That's that's medication reconciliation for that patient. And were you to pull them in a file review, you could count that patient because you know for a fact nothing was prescribed. If you didn't know that, if you're assuming nothing's prescribed, that's a problem. But if you know nothing's prescribed, that's MEDRIC. If you find out something was prescribed and you can double check to see if there is any kind of of, interference with that and another medication they're on, again, this could have been done automated, automatedly by automatically, excuse me, or an automated basis by perhaps their pharmacy benefit, management, through their health insurer. So you might have gotten a report that that nothing was was identified, so you don't have to do the work. Or the the individual medication was added to your med, list for that patient when you got the report and the system told you there were no interaction. That also would be medic medication reconciliation. Or you just found out when the patient walked in that they've been prescribed something, you got no report, so you're now double checking that that medication doesn't have any, side effects or interferences with other meds, you're doing med reconciliation. Any of those scenarios would also count. If the patient hasn't had a transition of care, that is they've only seen providers at your practice that, or in your organization that, that in that year, then at least once a year, you should be double checking. Are you on, you know, any supplements over the counter? Is this medication list that we have complete? And if so, if not, if there are any things to add, that's when you would do med rec. So just the the at least annually, if the patient hasn't had a transition of care, you must double check to make sure you have a complete accurate med list and you don't have any interactions or side effects you need to worry about. If they've had a transition of care that is they've seen any other provider, again, ED, hospital, medical specialist, behavioral health health specialist, whatever it is, then you would be checking, after they come in from that transition of care if they've had, any new Medicare you've been doing MedRec then. So it really depends on what the patient, is going through and how complex their care is and how many other providers they're seeing. But at least every year for every patient, if and and you would do it on an annual basis, you would you would do it for a patient, who has not seen another provider in a year. That's when you would wanna say, let's just do a med rec at this visit to make sure that we're we're up to speed. If they have had a transition, you're covered for that year. So that's what we're looking for. You may have different standards. There are a lot of folks that look at our medication reconciliation requirements and think they're a little too easy is not the right word, but but the bar isn't high enough, and that's fine. You can have a higher bar that you're measuring at. You may be doing med rec at every visit. And if that's the case, that may be something you're measuring internally. You're certainly gonna meet our requirement. But, also, you may be you may be, holding yourself that higher standard, and that's fine. You can always do sort of more, than that. So I just wanted to confirm that that was still the case. Go back to our slides. Oops. I should probably okay. So we're gonna talk a little bit about the FHIR review process itself if you are in fact pulling, records from the files. So this is the as I said, this is a method that we've been using for a long time because it does meet statistical significance testing. So when I was in grad school many, many years ago, this is back in the nineties before the Internet existed, and I can't believe I'm saying that. One of my statistics professors used to jokingly say, how big a sample do you need to have significant statistically significant results? And his joke was always as big as a sample as you can you can gather. That's actually not correct. Thirty records is sort of the minimum that statisticians would like to see in order to actually have statistically significant or the the ability to assess statistical significance in, performance. So we've used that thirty, level as well as our minimum for a lot of different, requirement. We use this in credentialing. We use this in, for our health plan programs and our, managed behavioral health care programs, so all those kinds of things. We've been doing this for quite a while. In this case, it would be thirty patient records of those who are actually in care management. So they're either either meeting the criteria you set in CMO one, where you're selecting different criteria in order to look for patients who are in care management, or CMO three, which is when you have that, electronic risk assessment, that's automatic for all your patients. And then you are also looking for a visit that is related to a condition for which they're in care management. So for instance, if you've got a patient who has diabetes and cardiovascular disease and is under treatment for anxiety, for instance, but they just came in for a flu shot, they just came in on a random Tuesday, got a flu shot, and left, and that's all they got. You wouldn't actually count that visit because that flu shot okay. You're all gonna start questioning me, but let's just say the flu shot was not related to what they they're in for care management. Now they have cardiovascular disease, so you may say a flu shot's really important. So let's take away the cardiovascular disease and the diabetes. Let's say they're being treated for anxiety and chronic migraine, and then they came in for a flu shot. You might say that's that's really not related to care management. So in order to identify patients, what we're gonna do is you're gonna pick the thirty most recent patients you've seen that are in care management and had a visit related to care management. And the way you do that is you basically, go thirty days into the past at least because we want you to have thirty days experience with patient. We don't want you to identify a patient who just was identified for care management yesterday. You haven't had a chance to to do all the work you need to do just to basically get them into care management. So we want you to have at least thirty days experience. So go back at least thirty days. Today is February seventeenth. So you would go back to January eighteenth, if I'm doing my math correctly, which was a Sunday. So you would go back to the Friday before. Just checking my cal I actually have a paper calendar up, and I'm checking it. And then you would basically say, okay. On that Friday, on January, sixteenth, which was the Friday, do we have any patients that we saw at this location that are in care management and were seen for a care management visit? That actually makes the for if you're pulling patients for file review, that actually makes it easier to assign them to a site. If you've got a patient that's going to more than one site and seeing perhaps the same, physician or the same team at each site because they move or they're seeing a lot of different providers, it can be hard to assign them. In in your electronic reports, you're gonna have to sort of pick a home base for them and assign them to that, probably where their primary care is practicing, predominantly. But if you're doing the file review management, if they came into site b on this date and that happens to be a care management related visit, then they're gonna be assigned to practice site b even though they might get the predominant amount of care at practice site a. And remember, it doesn't matter where they get care that counts in the file review. All you're doing is assigning them to a site for the purposes of saying, that's one of your thirty patients. That's all I'm talking about there. You're gonna and then so on the sixteenth, you're gonna say how many patients did we see at this site that for a visit related to care management that are in care management and say it's three. So then you say, okay. We're gonna take those three patients, all three of them, no matter what, sort of, state their care management is in. And then we're gonna go back to the fifteenth and say, many do we have on that date? Like, you're gonna keep going back until you have thirty patients with no breaks. You can't skip anybody. You can't decide that that, that they don't apply. And then once you hit that thirty patients, you're gonna wanna then know in your, file review, all we're gonna do is number the the patients down the side. You're gonna have to remember which or you have a list that say, this patient is patient one. This patient is patient two. We don't want that patient identification that the PHI, but you should have it at your end in case during an audit, we may come back and say, can you show me patient six? And you should know which patient that is and show in their record what you were pulling for evidence or what you were counting as evidence there. And if you wanna use another randomization system, you can, but you must get NCQA approval. We wanna make sure it's at least as statistically appropriate as this one. I really don't like that word. Very hard to say statistically. So the worksheet itself is one of the resources that comes with the actual standards themselves. You can download a copy of the the worksheet. And then if you, are actually using electronic, report and I can actually show you this in a real worksheet, once we, finish looking at the slides. If you are gonna use a report, you would actually say see report, and that will blank out the entire, criterion for the file review. So it would basically be telling the reviewer, don't look here for those data. If, you are, doing something that is not in the required work, the core requirements but elective, and you may not be doing it for every patient. You can say not used, and therefore, it will give you a zero for that item. So if you're doing elective items and, you just aren't aren't gonna answer one of the electives, you could just use not used, and that will zero out that, and and it will tell the reviewer not to not to look at For CM four and five, of course, those are required. Those are core requirements. You're going to have to, hit that seventy five percent threshold for them. If, you actually are doing this and you're pulling the data from file review, you're gonna say yes or no. This patient has evidence of this happening at least once in the last year. So, again, we're giving you twelve months from the date of the visit that they came in, to be able to to have evidence, and then you've gotta meet that seventy five percent, requirement. So I'm gonna stop sharing real quick. I just wanna show everyone what that file review looks like. There we go. So let me start sharing again. It brought up the right screen. If I could just find my cursor, that would be fantastic. So this is right now, what you actually get when you when you download the, standards guidelines electronically, what you get is that this is basically, one through nine here. That is the actual book. So if we were to actually publish a book again, we used to. They were were very large, very heavy, and very expensive, and no one liked it. So we now are are fully electronic. But, if we were to publish a book, this would be the the front matter is number one, then the standards and guidelines themselves, and then all of the appendices. There's also this resources folder, though, that comes when you download the electronic files, and that includes the record review workbook, a self assessment tool that we'll be going over next week in the on the twenty sixth in that office hours, and then some other items here that I won't go into right now. But here's the record review workbook itself. So I'm gonna bring that up, it's, of course, gonna open in a different screen. So let me slide it over when it's open. Okay. Bring this back over to share. So this is the record review workbook itself. I just wanna make sure you should be seeing that on my screen. I'm hoping you can. Can you just give me a a yes if you if you can see the instructions for the workbook? These instructions basically thank you. Alright. Just wanna make sure because it's not showing me the little share, outline on my screen, so I was getting worried. So these basically, I just went through all of these these instructions. And then the worksheet is actually gonna be whoops. Sorry. In this next tab, and we're gonna make this a little bigger. Where's my oops. There we go. So what you can see here is is you're gonna have your patients down here just numbered. Again, you should know who's number patient number one through patient number thirty. And then if we're gonna come in here and we're gonna say, we don't we're gonna do file review, but we don't, actually do patient person centered outcomes. So we're gonna say that one's not used, but we're gonna come in here and be able to say, yes. Whoops. Yes. Etcetera. And you can see down here, it will keep you a running tally. You've gotta get to the point of of thirty met and not met total. So you can see over here, we have the the zero out of thirty gives you a zero percent. But we've started here. We've got three patients, and we're at a sixty seven percent. So you would keep doing that as you're going through the patient records. Typically, you're gonna go through one patient record for all of these items, so you're you're not gonna necessarily go patient by patient, in the criterion, but you're gonna go through their file and start filling them out, you know, this way. And as you can see, you're getting this running total at the bottom that will show you, but you can't count the percentage, until you hit that thirty patient threshold. Relatively easy, once you actually are going through the files to be able to to record your data. But, again, you've gotta you've gotta have evidence in the patient file that, you have a patient centered care plan in the last year, you've updated it in the last year, that you've, provided a written requirement. Those are the two core requirements here, Centimeters five and four and five. And then everything else is is optional, is elective, but you still have to reach that seventy five percent threshold to get credit on the elective. Okay. Oops. So that was really the material we wanted to go through today on the file review. Happy to answer any questions about that or any other standards questions you've got, process questions that may apply to our PCMH program. Just a a shout out, we are still doing our individualized technical assistance program, so we are still looking, if you've got, health centers that are looking to get new recognition or, have new sites in transforming, and they they have other sites in annual reporting, we may be able to provide some financial assistance for them to complete those transforming reviews. So, feel free to contact us, if you are at all interested. We will also have, again, the next office hours at two o'clock on the twenty sixth, and that will be on the self assessment process. And I'll go over all those resources that are provided in the standards and guidelines for folks to use as a a way to prep for their own, surveys. Checking. I don't see any hands raised. No open questions? I thought I'll let you go a little oh, here we go. So the question, care plans with, details present over the course of several dates of service. To clarify for twenty twenty six the care plan for both dates, as reviewed, revised during the twelve months in between the I'm not sure, Don. I think that the so the question is basically looking at whether or not sort of everything for Centimeters four and five have to be done on the same dates of service the same date of service. Whereas I feel like your previous statement about it being, over several dates, certainly when you're getting someone started in your care management, it may take a few, visits before you actually have that full care plan that you've given to the patient. So, I'm going to actually I'll download the q and a report. I'm gonna send that through the policy dong because I wanna make sure we get a a good answer to that question. The elaborate on the patient self identity goal versus the treatment goal. So basically, idea of the patient reported outcomes is basically those are nonclinical outcomes. So the idea is or nonclinical goals the patient is setting that are still appropriate to to, treatment. So you might set, for instance, with somebody with cardiovascular disease, you might set specific blood pressure goals, for that patient, to be able to maintain. But that patient may be more concerned about, for instance, or maybe you're also setting, weight loss goals, in terms of percentage, that kind of thing. Your patient, on the other hand, may be, more concerned about their ability to function, in the world. So they're less concerned about whether or not their blood pressure is under control, or their what their weight is. They may be more concerned about, can I go shopping, with my daughter-in-law? I'll I'll use an example, without having to sit down. So am I have I lost enough weight, and am I functional enough that I can walk around the shopping mall? Do people still do that? I'll I'll use that shopping area for an afternoon without having to to stop and rest. That would be a outcome goal that's patient, identified and patient self reported that is important to them that still gives you a clue as to their function and how they're doing with their care, but it's less about specific numbers and clinical measures. So it's just something more salient to the patient. And that's what we're looking for in Centimeters ten and eleven. So so a pay the question comes in. Patient goals that are general but not appropriate to the treatment would not satisfy the requirement. And the goal of providers, I wanna be healthier for my grandkids and not see not need so much medication. I think, yeah, that's a little too vague. I would look at the second saying and and say not need not need so much medication. I know, for instance, with some patients when they're on, when they have type two diabetes, if they lose a significant amount of weight, they may be able to stop certain meds. And that may be the way that you could, measure it as a self reported goal. So I wanna be able to get to the point where I don't need, this, all of these medications, and I could drop a medication in the next year. That could be a goal. But I think I just wanna be healthier for my grandkids. Wonderful sentiment. But is there a way that you can get that to a measurable goal, something that you could see actual change in? So is it, you know, classic example is playing with my grandchildren for x amount of time in the backyard without breathing heavily, that kind of thing. So, yeah, that that I think you but you could start with that basis and drill down to get something more salient to the patient, which I think is great. Alright. I don't see any other questions, So I will let you go a little early. You don't have to use the full hour. Thank you for tuning in. Again, the next one is February twenty sixth at two o'clock. And, of course, if you have any questions, you can always contact us. So barriers to address would be any goal that is in the care plan. So you'd be looking at, barriers pretty much at any or all of the goals, assessing those. And, of course, when you assess barriers that may be, no. We're making progress and we feel comfortable about it, so there are no barriers. So, that would be based on the goals that are in the treatment plan itself, specifically. Alright. Well, I thank you all for joining us. I hope you can be here next week, and we will, so it's seventy five percent for care plans by site. Yes. So so seventy five percent of patients in care management should have a written care plan that they have received to meet their core requirements for Centimeters four and five. Alright. Well, hope everyone has a good afternoon and evening.