Compass Practice Transformation Network (PTN) User Guide

Transcription

1 Compass Practice Transformation Network (PTN) User Guide Page 1

2 Table of Contents 1 Preface Introduction Operational Model How to Use this User Guide System Availability and Requirements Hardware Software Internet Connection System Availability System Timeout and Automatic Logout Account Registration and Logging in to Compass PTN Portal Registering for a Compass PTN Portal User Account Apply for a Compass PTN Portal User Account Account Login First Time Users Established Users Retrieve Forgotten Username Reset Forgotten Password Enrolling Practices Requesting Account Logging into Compass PTN portal Enrollment Dashboard Enroll Single Practice Practice Information Section Practice Information Save and Complete Later Clinician Information BAA Upload Submit for Review Page 2

3 Enroll Multiple Practice Compass PTN Portal Navigation Welcome Screen Manage QI Work Plans Selecting a Practice Filtering Practices Manage QI Work Plans Screen Left Navigation Manage QI Work Plans Screen Left Navigation Year Section Manage QI Work Plans Screen Left Navigation Add Work Plan Section Manage QI Work Plans Screen - Body of Screen Manage QI Work Plans Screen Top of Screen Detail Manage QI Work Plans Screen Panel Level Clinician Selection Manage QI Work Plans Screen Clinical Topics Clinical Topic Question Clinical Topic Question Clinical Topic Question Clinical Topic Question Clinical Topic Question Manage QI Work Plans Screen - SAVE, CANCEL, DELETE Functions Retrieve a Saved Work Plan Custom Clinical Topic Uploading QRUR/Strategic Plan Quality Measure Performance Data Reporting Overview Quality Measure Performance Data Submission Requirements Quality Measure Performance Data Submission Methods Manual Entry of Patient-Level Data Manual Entry of Aggregate Measure Performance Data Quality Reporting Document Architecture (QRDA) III File Upload Determining Your Practice's Data Submission Method(s) Patient-Level Quality Measure Data Submission Overview Page 3

4 8.2 Frequency of Data Entry Data Abstraction Worksheet Sampling Compass PTN Portal Instructions for Patient-Level Data Entry Provider Lookup Measure Status View Patients View Passing Patients View Failing Patients View Excluded Patients View Patient Details Add New Patient Search for a Patient Patient Summary Screen Patient Demographics Add Visit Vitals Tab Labs Tab Allergies Tab Diagnoses Tab Immunizations Tab Medications Tab Procedures Tab Edit Visit Data Add Element Add Allergy Element Add Diagnosis Element Add Immunization Element Add Lab Element Add Medication Element Add Procedure Element Page 4

5 Add Vital Element Adding Exclusions Edit Element Measure Status Clinical Summary Custom Measures Creating Custom Measures Navigation to Create Custom Measures Filling out Custom Measure Form Reporting on Custom Measure Removing Custom Measures Page 5

6 List of Figures Figure 1. Login Screen Figure 2. Terms of Use Screen Figure 3. Set New Password Figure 4. Choose Security Question Figure 5. Navigate to Home Figure 6. Login Screen - Forgot Username Figure 7. Login Screen Forgot Username Address Figure 8. Login Screen Forgot Username Security Question Figure 9. Login Screen Forgot Password Figure 10. Login Screen Forgot Password Enter User Name Figure 11. Login Screen Forgot Password Security Question Figure 12. Request account Figure 13. Create Account Figure 14. Logging into Portal Figure 15. Enrollment Dashboard Figure 16. Enroll Single Practice Figure 17. Health System Information Section Figure 18. Practice Information Tab Figure 19. Practice Information Figure 20. Additional Sections Figure 21. Clinician Template Figure 22. Upload Clinician Figure 23. BAA upload Figure 24. BAA Upload Screen Figure 25. Submit for Review Figure 26. Home/Welcome Screen Figure 27. Select a Practice Screen Figure 28. Select a Practice Screen Filtered Figure 29. Manage QI Work Plans Screen Left Navigation Figure 30. Manage QI Work Plans Screen Left Navigation Year Section Figure 31. Manage QI Work Plans Screen Left Navigation - Add Work Plan Section Figure 32. Manage QI Work Plans Screen Figure 33. Manage QI Work Plans Screen Top of Screen Detail Figure 34. Manage QI Work Plans Screen Panel Level Clinician Selection Figure 35. Manage QI Work Plans Screen Clinical Topics Figure 36. Clinical Topic Question 1 - Asthma Figure 37. Clinical Topic Question 1 - Reduction of Unnecessary Testing Page 6

7 Figure 38. Clinical Topic Question 1 - Reduction of Unnecessary Testing Additional Answer Values Figure 39. Clinical Topic Question Figure 40. Clinical Topic Question Figure 41. Clinical Topic Question Figure 42. Clinical Topic Question Figure 43. SAVE, CANCEL, DELETE Functions Figure 44. Custom Clinical Topics Figure 45. QRUR and Strategic Plan Upload Buttons Figure 46. QRUR Upload Screen Figure 47. Provider Lookup Link Figure 48. Provider Lookup Filter by Provider Title Figure 49. Patient-Level Data Entry - Measures Dashboard Figure 50. Patient-Level Data Entry - Measures Dashboard Status Bar Figure 51. Patient-Level Data Entry - Measures Dashboard Passing Status Figure 52. Patient-Level Data Entry - Measures Dashboard Failing Status Figure 53. Patient-Level Data Entry - Measures Dashboard Breakdown of Failing Patients Figure 54. Patient-Level Data Entry - Measures Dashboard Excluded Count Figure 55. Patient-Level Data Entry - Measures Dashboard Breakdown of Excluded Patients Figure 56. Patient-Level Data Entry - Measures Dashboard Drill-Down to Patient Figure 57. Measure Status on Patient Summary Screen Figure 58. Measure Status Link to Measure Details Figure 59. Patient-Level Data Entry - Add New Patient Link Figure 60. Add New Patient Screen Figure 61. Patient Summary Screen - Save Patient Button Figure 62. Patient-Level Data Entry - Search for a Patient Link Figure 63. Patient-Level Data Entry - Patient Search Results Figure 64. Patient Summary Screen - Edit Patient Icon Figure 65. Edit Patient Details Screen Figure 66. Patient Summary Screen - Add Visit Button Figure 67. Add Visit Screen Figure 68. Add Visit Screen - Edit Field Button Figure 69. Add Visit Screen - Clinical Code Search Figure 70. Add Visit Screen - Clinical Topic Tabs Figure 71. Add Vitals Screen Figure 72. Add Vitals Screen - Cancel and Submit Buttons Figure 73. Vitals Tab - Vitals Listing Figure 74. Add Lab Screen Figure 75. Add Lab Screen - Cancel and Submit Buttons Figure 76. Labs Tab - Lab Listing Page 7

8 Figure 77. Add Allergy Screen Figure 78. Add Allergy Screen - Cancel and Submit Buttons Figure 79. Allergies Tab - Allergy Listing Figure 80. Add Diagnosis Screen Figure 81. Add Diagnosis Screen - Cancel and Submit Buttons Figure 82. Diagnoses Tab - Diagnoses Listing Figure 83. Add Immunization Screen Figure 84. Add Immunization Cancel and Submit Buttons Figure 85. Immunizations Tab - Immunization Listing Figure 86. Add Medications Screen Figure 87. Add Medications Screen - Cancel and Submit Buttons Figure 88. Medications Tab - Medication Listing Figure 89. Add Procedure Screen Figure 90. Add Procedure Screen - Cancel and Submit Buttons Figure 91. Procedures Tab - Procedure Listing Figure 92. Patient Summary Screen - Edit Visit Icon Figure 93. Edit Visit Screen - Delete Code Button Figure 94. Procedures Tab - Add Procedure Button Figure 95. Add Procedure Screen Figure 96. Visit Screen - Cancel and Submit Buttons Figure 97. Patient Summary Screen - Save Patient Button and Link Figure 98. Patient Summary Screen - Add Element Button Figure 99. Patient Summary Screen - Add Allergy Element Button Figure 100. Add Allergy Element Screen Figure 101. Add Allergy Element Screen - Cancel and Submit Buttons Figure 102. Patient Summary Screen - Add Diagnosis Element Figure 103. Add Diagnosis Element Screen Figure 104. Add Diagnosis Element Screen - Cancel and Submit Buttons Figure 105. Patient Summary Screen - Diagnosis Element Added Figure 106. Patient Summary Screen - Add Immunization Element Figure 107. Add Immunization Element Screen Figure 108. Add Immunization Element Cancel and Submit Buttons Figure 109. Patient Summary Screen - Immunization Element Added Figure 110. Patient Summary Screen - Add Lab Element Figure 111. Add Lab Element Screen Figure 112. Add Lab Element Screen - Cancel and Submit Buttons Figure 113. Patient Summary Screen - Add Medication Element Figure 114. Add Medication Element Screen Figure 115. Add Medication Element Screen - Cancel and Submit Buttons Page 8

9 Figure 116. Patient Summary Screen - Medication Element Added Figure 117. Patient Summary Screen - Add Procedure Element Figure 118. Add Procedure Element Screen Figure 119. Add Procedure Element Screen - Cancel and Submit Buttons Figure 120. Patient Summary Screen - Procedure Element Added Figure 121. Patient Summary Screen - Add Vital Element Figure 122. Add Vital Element Screen Figure 123. Add Vital Element Screen - Cancel and Submit Buttons Figure 124. Patient Summary Screen - Vital Element Added Figure 125. Patient Summary Screen - Add Exclusion Element Figure 126. Add Exclusion Element Screen Figure 127. Add Exclusion Element Screen - Cancel and Submit Buttons Figure 128. Patient Summary Screen - Exclusion Element Added Figure 129. Patient Summary Screen - Edit Element Icon Figure 130. Edit Vital Element Screen - Delete Code Button Figure 131. Edit Vital Element Screen - Code Deleted Figure 132. Edit Vital Element Screen - Cancel and Submit Buttons Figure 133. Patient Summary Screen - Measure Status Column Figure 134. Patient Summary Screen - Selectable Measure Name Link Figure 135. Measure Criteria List Example for Heart Failure Beta-Blocker Therapy Measure Figure 136. Measure Criteria Example for Diabetes A1c Poor Control Measure Figure 137. Measure Criteria Example with Link to Enter Patient Diagnosis Figure 138. Measure Criteria Example - Close Button Figure 139. Measure Status Unavailable Figure 140. Patient Summary Screen - Clinical Summary Link Figure 141. Clinical Summary Figure 142. Custom Measure Selection Figure 143. Custom Measure Form Figure 144. Custom Measure Preface The Iowa Healthcare Collaborative (IHC) has organized a multi-state Practice Transformation Network (PTN) to support healthcare transformation for over 7,000 clinicians across Iowa, Nebraska, South Dakota, Kansas, Wisconsin, Oklahoma and Georgia. The PTN partners have defined an innovative four-year model that uses a centralized infrastructure of education and data management to deploy local transformation activities through an integrated network of state-based partners. Page 9

10 The purpose of this document is to provide a description of the functionality of Compass PTN Portal, the applications for reporting data for the Compass Practice Transformation Network (PTN), and to provide Compass PTN users with step by step instructions. For program questions, contact: Melissa Kapping, MSN, RN, CPHQ Phone: (515) kappingm@ihconline.org For additional information, contact: Compass PTN Support 1776 West Lakes Parkway West Des Moines, IA Phone: CompassPTNSupport@telligen.com Page 10

11 2 Introduction The Compass PTN is supporting healthcare transformation for over 7,000 clinicians across Iowa (IA), Nebraska (NE), South Dakota (SD), Kansas (KS), Wisconsin (WI), Oklahoma (OK) and Georgia (GA). Approximately 52% of recruited clinicians serve in rural and/or medically-underserved areas. The Compass PTN is part of an innovative four-year model, using a centralized infrastructure of education and data management to deploy local transformation activities through an integrated network of statebased partners. Compass PTN Portal is the robust web application utilized by Compass PTN for collection of clinical data, through direct entry for reporting Clinical Quality Performance measurement data, and Quality Improvement Work Plan creation. 2.1 Operational Model The operational model organizes the network around a centralized infrastructure that provides data management, educational support, and technical assistance to achieve TCPI aims. The Compass PTN is working with partners that have established relationships within state-based organizations and have impacted provider transformation through previous and on-going work. All partners will carry out the core functions of the PTN operational plan in their state or geographic region. Core functions include recruitment, technical assistance for clinicians and practices, as well as sharing of PTN educational resources and best practices. This model is deployed regionally to maximize efficiency, sustainability, and ability to address regional variation. The following are the list of partner organizations working within the Compass PTN. Iowa Healthcare Collaborative Prime Contractor is a provider-led and patient-focused nonprofit organization. IHC has served as one of the Partnership for Patients (PfP) HEN. IHC will lead all IA PTN activities. Telligen IT Subcontractor and Contractor has over 40 years of experience with CMS quality improvement initiatives and will provide PTN data collection and analysis services and QI Advisor support. Wisconsin Collaborative for Healthcare Quality - Contractor is a voluntary, non-profit consortium of 36 organizations committed to improving quality and affordability of healthcare in the state. WCHQ will serve as the WI state-based convener. HealthPOINT at Dakota State University - Contractor is a HIT Regional Extension Center and will serve as the state-based convener for SD. Page 11

12 Georgia Hospital Association Research and Education Foundation - Contractor is a provider-led membership organization. They will serve as the GA state-based convener. The Kansas Healthcare Collaborative (KHC) - Consultant is a provider-led and patient-focused nonprofit organization. KHC will serve as the KS state-based convener. OU Physicians Consultant With more than 600 doctors, OU Physicians is the state s largest physician group and will serve as the state-based convener for OK in conjunction with Telligen. Table 1. PTN Lead and State-Based Partner Organizations 2.2 How to Use this User Guide The User Guide is designed for use by practices participating in the Compass PTN, as well as QI Advisor users assisting the practices. The goal of this guide is to: Provide a clear picture of the overall purpose of Compass PTN Portal Provide users with detailed guidelines and instructions on how to use Compass PTN Portal to create work plans, and collect and report quality measure data Page 12

13 3 System Availability and Requirements 3.1 Hardware Screen resolution: 800 x 600 minimum, 1024 x 768 preferred. 3.2 Software Internet browsers: Microsoft Internet Explorer 11.0 and above Google Chrome, version 32 or above Safari or above Mozilla Firefox Web Browser cookies enabled JavaScript enabled Pop-up blockers disabled Operating systems: Microsoft Windows 7. Users may open Compass PTN Portal in other operating systems, but they are not supported at this time. 3.3 Internet Connection Compass PTN Portal is accessible via any high-speed Internet connection (minimum of a 56k modem). 3.4 System Availability Compass PTN Portal is available 24 hours a day, 7 days a week at Users are notified by about scheduled and unscheduled system maintenance. Scheduled maintenance occurs every other Tuesday evening from 7:00 PM Central Time (CT) through 11:00 PM CT. Compass PTN Portal may not be available during those times. 3.5 System Timeout and Automatic Logout You will automatically be logged out after 30 minutes of inactivity in Compass PTN Portal. You will receive a message that you have been logged out. Page 13

14 4 Account Registration and Logging in to Compass PTN Portal 4.1 Registering for a Compass PTN Portal User Account Apply for a Compass PTN Portal User Account Each application user will be ed their User Name and a temporary Password. The temporary password expires in 24 hours. If the temporary password is allowed to expire, Compass PTN Support will need to be contacted by phone at or via at CompasPTNSupport@telligen.com. 4.2 Account Login This section provides guidance for the user to log in to Compass PTN Portal. Open a supported browser (Chrome, Mozilla Firefox, or Internet Explorer) Go to the Compass PTN Portal site at Figure 1. Login Screen First Time Users 1. Enter the User Name and temporary Password sent to you via and select the Sign In button. You must login and select the Change Password link at the top of the screen to reset your password within 24 hours of receiving your temporary password, as your password will expire after 24 hours. 2. Select the Change Password link at the top of the screen. A Terms of Use screen displays. Page 14

15 3. Select the I Agree button Figure 2. Terms of Use Screen You will be prompted to set a new password: Figure 3. Set New Password Create a new password following the password requirements: Minimum length 6 characters Page 15

16 Must have at least one lower case letter Must have at least one number Must have at least one special character - allowed characters # $ % & * ( ) - = + [ { ] } ; :, / Confirm the new password in the Enter Again field and click Save You will be prompted to choose a reminder question and provide an answer: Figure 4. Choose Security Question Select one security question from the following list, provide an answer to that security question, and select Save: What is your father's middle name? What is your library card number? What is your primary frequent flyer number? What was your first phone number? What was your first teacher's name? Write my own question After setting your security question, you are redirected to a screen notifying you that you are currently signed in, but navigated away from the main portal screens. Select the Home option in the gray menu bar to return to the Home screen. Page 16

17 Figure 5. Navigate to Home Established Users Enter User Name and Password and select the Sign In button Retrieve Forgotten Username The Forgot Username function provides sign-in assistance. You must complete the following steps: 1. Select the Forgot Username link located below the red Sign In button on the login screen. Figure 6. Login Screen - Forgot Username Page 17

18 2. You are prompted to insert the address associated with your Compass PTN Portal account. Type the address associated with your account in the text box provided and select the Submit button. Figure 7. Login Screen Forgot Username Address 3. The following notification displays, asking you to answer your selected security question. Once you enter your answer and click the Submit button, an with your User Name is sent to the associated address. Figure 8. Login Screen Forgot Username Security Question 4. You must access your account to retrieve the forgotten User Name. Once the User Name is retrieved, you may use it to log into Compass PTN Portal. If you have also forgotten the password, refer to the Reset Forgotten Password instructions Reset Forgotten Password The Forgot Password function provides sign-in assistance. You must complete the following steps: 1. Select the Forgot Password link located below the Sign In button on the login screen. Page 18

19 Figure 9. Login Screen Forgot Password 2. Enter your user name in the User Name field that appears, and select the Submit button. Figure 10. Login Screen Forgot Password Enter User Name 3. Type in the answer to the Security Question and select the Submit button. Figure 11. Login Screen Forgot Password Security Question Page 19

20 4. Retrieve the temporary password from your , and use it to log in to Compass PTN Portal. 5. You will be prompted to enter a new password and confirm the new password. Page 20

21 5 Enrolling Practices 5.1 Requesting Account Practices that are interested in enrolling within the Compass PTN, will first need to request an account from the Compass PTN support Team. Navigate to the following page and select Request an account. Figure 12. Request account After selecting request an account, users will be directed to the below screen (see Figure 2) that will allow them to enter their information to gain access to the Compass PTN portal. Page 21

22 Figure 13. Create Account After registering for an account for the Compass PTN two s will be sent to the address provided within figure 2. This process can take up to 24 hours. 5.2 Logging into Compass PTN portal Once you have received your username and password you will be able to log into the Compass PTN portal. Please note that all temporary passwords that are received via will expire after 48 hours, it is important that you log into the Compass PTN portal prior to the password expiring. Page 22

23 Figure 14. Logging into Portal Once you have log in select the home button from the top left corner of the screen. 5.3 Enrollment Dashboard The home button will navigate Compass PTN participants to the enrollment dashboard where users can enroll practices to participant within the Compass PTN. The enrollment dashboard gives Compass PTN participants two option to enroll practices. In addition to enrolling new practices, any practice that is already enrolled or still in the process of enrolling will show up on the enrollment dashboard. Figure 15. Enrollment Dashboard Page 23

24 5.4 Enroll Single Practice First time users select the enroll single practice, a pop up will appear asking users if they are part of a health system. Important users will only be able to ask this question once upon enrolling their first practice. Figure 16. Enroll Single Practice By selecting Yes this will bring users to the Health system information page. All information that is entered on the Health System Information page will persist to all practices that are enrolled with this user. Page 24

25 Figure 17. Health System Information Section Within the Health System Information section any field that is not noted as optional is a required field and will need to be filled out to complete the Health System Information section. Once all the required fields are filled out select the Finalize and Continue button from the bottom of the page. If all required information is present a green success banner will appear at the top of the page. If there are any errors or required information that is missing from the Health Information section a yellow or red banner will appear with an error message. 5.5 Practice Information Section After saving the health information section, navigate to the Practice Information section by selecting the Practice information tab at the top of the page. If you selected that you are not part of a health system from the enrollment dashboard the practice information section will be the first section that will need to Page 25

26 be filled out. Figure 18. Practice Information Tab Figure 19. Practice Information 5.6 Practice Information The practice information tab will have two sections, the first section will be the practice information which will cover basic practice demographic information. The second section will be the Program participation. Like the health system information section any question that is not labeled as optional is required. Page 26

27 5.7 Save and Complete Later The practice information section can be saved by selecting the save and complete later. However, to select the save and complete later the practice name and the State must be filled out. This will allow the Compass PTN portal to create a unique identifier within the Compass PTN portal. After the practice information section has been saved once, two additional sections will appear. The Submission information section and the Clinician information section. The clinician information section will be the area that will allow participants to associate their providers to the practice. Figure 20. Additional Sections 5.8 Clinician Information Click the clinician information section and the tab will expand, within this section there will be a template to download. Compass PTN participants will be able list all clinicians that are working at the practice. Selecting the blue hyperlink will download the template onto the hard drive of your computer. After filling out the form select the upload clinician file. Page 27

28 Figure 21. Clinician Template Figure 22. Upload Clinician Please follow all the formats that are listed within the clinician template, any formatting issue that occur will cause a delay with processing your file. Once the file has been uploaded select the enrollment form tab from the top of the screen to navigate back to the enrollment form. Page 28

29 5.9 BAA Upload The final step to the enrollment process will be filling out a BAA and uploading this file to the Compass PTN. Figure 23. BAA upload Select the BAA upload tab from the top of the page. This will bring you to the BAA upload that will allow users to complete the required BAA form. Like the clinician upload page selecting the blue hyperlink will download the BAA for your practice to download and sign. Figure 24. BAA Upload Screen Page 29

30 Submit for Review Once all the forms have been uploaded and the required questions have been filled out you will now be able to place the enrollment form into a submitted status by selecting the Submit for Review. This button will only appear after all the required forms have been uploaded to the Compass PTN portal. Figure 25. Submit for Review After the submit for review button has been selected the enrollment form will be in a submitted status. A member of the Compass PTN team will review your enrollment application and either approve your practice or require additional information. Enroll Multiple Practice The enroll multiple practice option is meant to be used for practices that are part of a large health system and enrolling more than 5 practices. Any user that uses the enroll multi practice option Must be part of a Health system. This option will allow users to fill out a template with all their practice information and then upload the file into the Compass PTN portal. Once the file is process users will be able to log into the portal and complete the rest of the enrollment process. Users that use the multi practice upload process will still need to upload a BAA file and a clinician file to complete the enrollment process. Page 30

31 6 Compass PTN Portal Navigation 6.1 Welcome Screen Upon login, you are navigated to a Welcome screen. The left side of the screen, under the heading What would you like to do?, contains a navigation link for Manage QI Work Plans. Other links will be added in future releases. A Logout link is located in the upper right corner of each screen. Figure 26. Home/Welcome Screen 6.2 Manage QI Work Plans Selecting a Practice Selection of the Manage QI Work Plans link will display a Select a practice box, listing all of the practices participating in the Compass PTN to which you have access, listed by name and PTN Practice ID. QI Advisor users will see all PTN practices associated with their PTN Partner organization. Practice Admin users will see only those one or more practices for which they ve been identified as the primary point of contact. Page 31

32 Figure 27. Select a Practice Screen You will select the radio button in front of the desired practice, and then select the GO button to navigate to the Manage QI Work Plans screen for the selected practice Filtering Practices You can filter the list of practices by typing in either the practice name or the PTN Practice ID of a practice in the filter field above the table of practices. The Practice ID is a unique ID number assigned to each practice participating in the Compass PTN. The list will begin to filter based on what is typed in the filter field. In this example, cherry was entered in the filter, which filters the list to only the practices that contain "cherry" within the practice name. Select the radio button in front of the desired practice, and then select the GO button to navigate to the Manage QI Work Plans screen for the selected practice. Page 32

33 Figure 28. Select a Practice Screen Filtered Manage QI Work Plans Screen Left Navigation If a Work Plan has not been created for the current PDSA cycle, a blank Work Plan is displayed for you to complete, as seen in the figure below. The Manage QI Work Plans screen contains a left navigation area, with 1) an expandable year section, and 2) a section to add a new work plan. Page 33

34 Figure 29. Manage QI Work Plans Screen Left Navigation Manage QI Work Plans Screen Left Navigation Year Section Expanding year 2016 in the left navigation area displays the three 4-month PDSA cycles within the year - Cycle 1 (Jan 2016 Apr 2016), Cycle 2 (May 2016 Aug 2016), and Cycle 3 (Sept 2016 Dec 2016). Under each PDSA cycle are the links to the individual Work Plan(s) the practice has entered in that cycle. In this example, Cycle 1 has a work plan entered. Practices must complete a minimum of one work plan per cycle, and may enter two if needed. Figure 30. Manage QI Work Plans Screen Left Navigation Year Section Page 34

35 Manage QI Work Plans Screen Left Navigation Add Work Plan Section The Add Work Plan section has a Year dropdown for selection of the year. The Cycle dropdown (expanded below in Figure 18) allows you to select the PDSA cycle for which you want to add an additional work plan within that year. After selecting the Year and Cycle, select the ADD WORK PLAN button. Figure 31. Manage QI Work Plans Screen Left Navigation - Add Work Plan Section Manage QI Work Plans Screen - Body of Screen The body of the Manage QI Work Plans screen displays the name of the Work Plan at the top of the screen, as seen next to the number 1 below. The name is defaulted to "QI Work Plan 1 Cycle 1 (Jan Apr 2016" prior to entering work plans for Quarter 1. The name may be left as displayed when a work plan is entered, but you are encouraged to change it to make it unique and meaningful for that work plan. Selecting the pencil icon to the right of the name turns the name into an editable text box. When the name is changed and the screen is saved, the name of the work plan in the left navigation section will also be updated to reflect the change. The Status field, as shown next to the number 2 below, will display as Not Complete until all of the required fields have been answered. When all requirements have been met, the status will automatically update to Complete. Page 35

36 Figure 32. Manage QI Work Plans Screen Manage QI Work Plans Screen Top of Screen Detail As shown below, detailed information at the top of the body of the screen includes the following: 1) The Compass PTN Practice name and ID 2) The name of the QI Advisor assigned to the practice 3) The Work Plan Start Date, entered by selecting the calendar icon and choosing a date, or manually entered in the format shown (mm/dd/yyyy) 4) The name(s) of the Practice Point(s) of Contact 5) The Level of Implementation allows the practice to identify if the Work Plan will be implemented at the entire Practice level across all clinicians in the practice, or at the Panel level for one or more clinicians, but not all clinicians Page 36

37 Figure 33. Manage QI Work Plans Screen Top of Screen Detail Manage QI Work Plans Screen Panel Level Clinician Selection If "Panel level (individual clinician)" is chosen for the Level of Implementation, the screen expands for the practice to select the clinician(s) who will be focusing on the work plan. The Available Clinicians box shows all of the clinicians at the practice. The clinician(s) in the Selected Clinicians box are those that are focusing on the work plan. You may move the clinicians between the Available and Selected Clinician boxes by highlighting one or more names and clicking the appropriate arrow icon. In the following example, Bob Robertson has been selected as the clinician who will be focusing on this work plan. Figure 34. Manage QI Work Plans Screen Panel Level Clinician Selection Page 37

38 Manage QI Work Plans Screen Clinical Topics The lower portion of the body of the Manage QI Work Plans screen contains an expandable/collapsible section for each of the following clinical topics: Asthma Closure of the Referral Loop Diabetes Documentation of Current Medications in the Medical Record Heart Failure Hypertension Reduction of Unnecessary Testing Unnecessary Hospitalizations Avoided Upper Respiratory Infection Custom Clinical Topic Figure 35. Manage QI Work Plans Screen Clinical Topics Clinical Topic Question 1 For either the Practice Level or Panel Level implementation, practices must complete each of the clinical topic sections of the work plan. Each clinical topic section contains the same questions, with just a few minor differences. In all of the clinical topic sections, you may select the first checkbox, as shown next to number 1 in the figure below, to indicate that the topic does not apply to the practice. For example, if the practice is a specialty practice that does not treat asthma, you may select the first checkbox under the Asthma clinical topic. When the first checkbox is selected, questions 1 through 5 below the checkbox will not apply, and will not be answered. Page 38

39 Any time an Other answer option is provided throughout questions 1 through 5, a description must be entered in the associated text box. Question 1 for the Asthma topic, as shown next to number 2 in the figure below, is the only question that contains clinical topic-specific answer options. You are asked to identify one or more clinical topicrelated actions and best practices the practice will implement during the PDSA cycle to assist in meeting the practice's improvement goal for the specific clinical topic. Figure 36. Clinical Topic Question 1 - Asthma The first question for the Reduction of Unnecessary Testing and Unnecessary Hospitalizations Avoided clinical topics is slightly different from the other topics. The practice must first select one or more measures on which they will focus during the PDSA cycle. See the first question for the Reduction of Unnecessary Testing topic in the following figure. Page 39

40 Figure 37. Clinical Topic Question 1 - Reduction of Unnecessary Testing For each measure selected, additional answer values are displayed to allow the practice to identify the clinical topic-specific actions and best practices they will implement for that selected measure. The figure below shows the additional answer values displayed when the Imaging Studies for Low Back Pain measure was selected. The additional answer values are specific to the measure(s) selected. Figure 38. Clinical Topic Question 1 - Reduction of Unnecessary Testing Additional Answer Values Page 40

41 Clinical Topic Question 2 Question 2 under each clinical topic asks you to identify which performance improvement method(s) the practice will utilize for meeting their goal for the clinical topic. If the Other checkbox is selected, a brief description is required. Figure 39. Clinical Topic Question Clinical Topic Question 3 Question 3 asks you to identify one or more practice improvement activities the practice will incorporate during the PDSA cycle. These include things such as training of staff, patient education, and patient outreach campaigns. Page 41

42 Figure 40. Clinical Topic Question Clinical Topic Question 4 Question 4 requires entry of a SMART goal for the clinical topic and PDSA cycle. SMART goals are specific, measurable, achievable, results-focused, and time bound. For example, Increase the Asthma measure performance rate by 0.5% by the end of April This goal, along with the QI Work Plan Start Date, will be displayed on the monthly quality reports that you will be able to generate in a future release of Compass PTN Portal. Figure 41. Clinical Topic Question Clinical Topic Question 5 The fifth question asks you to indicate one or more ways the practices plans to measure the outcome of their activities they perform for the clinical topic during the PDSA cycle. Page 42

43 CLEAR Button As shown at the bottom of the figure below, each clinical topic section has a CLEAR button below Question 5. Selection of the CLEAR button will clear the answers to all questions within that clinical topic. Figure 42. Clinical Topic Question Manage QI Work Plans Screen - SAVE, CANCEL, DELETE Functions Buttons at the bottom of the body of the QI Work Plan screen give the user the ability to perform the following functions: SAVE: The SAVE button saves all answers the user has entered. CANCEL: The CANCEL button will cancel any changes the user has made since the last time they saved the screen, and restore the screen to its previous state. When the user selects the CANCEL button, a pop-up message displays for the user to verify that they want to cancel their changes: o Selecting OK in the pop-up message will cancel any changes o Selecting Cancel in the pop-up message will return to the screen without canceling changes Page 43

44 DELETE: The DELETE button will delete the entire QI Work Plan. When the user selects the DELETE button, a pop-up message displays for the users to verify that they want to delete the work plan: o Selecting OK in the pop-up message will delete the entire QI Work Plan o Selecting Cancel in the pop-up message will return to the screen without deleting the QI Work Plan changes Figure 43. SAVE, CANCEL, DELETE Functions Retrieve a Saved Work Plan After a Work Plan has been saved, it is available for review by the user. The user will follow the steps below to retrieve a saved Work Plan: Select the Manage QI Work Plans link in the left navigation panel Select the desired practice from the Select a practice screen On the QI Work Plan screen, reference the left navigation panel to select the Year, Cycle, and then the Work Plan you would like to review 6.3 Custom Clinical Topic The custom clinical topic section allows users to free text information that is relevant to the clinical topic that they are currently working. The Custom Clinical Topic will allow Compass PTN users to create their own clinical topics for either a measure that is not be reported on within the Compass PTN portal, or to provide additional details that is not being captured within one of the other section of the QI work plan. Page 44

45 Figure 44. Custom Clinical Topics 6.4 Uploading QRUR/Strategic Plan The QI work plan allows practices to upload a strategic plan and a QRUR. This is found on the QI work plan page and allows Compass PTN users to upload either a word document or a PDF file to the Compass PTN portal. Page 45

46 Figure 45. QRUR and Strategic Plan Upload Buttons Once the files have been uploaded users can manage the files from the upload pages. PTN participants can either download a file that has been uploaded to the portal or remove a file that is no longer relevant to the practice. Figure 46. QRUR Upload Screen Page 46

47 7 Quality Measure Performance Data Reporting Overview 7.1 Quality Measure Performance Data Submission Requirements Practices enrolled in the Compass Practice Transformation Network (Compass PTN) must submit clinical quality measure performance data for each clinician monthly via Compass PTN Portal. Data may be reported for as many of the quality measures as possible, but must be submitted for a minimum of one measure applicable to the clinician. Data can be submitted using any of the three methods described below; the method of submission will depend on the practice s electronic capabilities. 7.2 Quality Measure Performance Data Submission Methods Practices must select a single method of data submission each month per measure they are reporting, but will have flexibility to change the data submission method from month to month if needed (e.g., a practice implements a new electronic health record (EHR) at some point during the initiative). A summary of the data submission methods is provided below. Detailed instructions for each method are provided later in this user guide. NOTE: Each of the submission methods will be rolled out over the next few months, starting with the patient-level data entry method. The screens to manually enter aggregate measure data will be available by mid-march, and the ability to upload QRDA III files will be available by mid-april. Instructions for aggregate measure data entry and QRDA III file upload will be available in the user guide when those methods become available Manual Entry of Patient-Level Data Practices without an EHR or an alternative electronic tool to collect and calculate quality performance data may securely enter patient-level demographic and clinical data into the Compass PTN Portal application, similar in fashion to a web-based EHR. Step-by-step instructions and screen shots are provided later in this user guide to help practices through the basic data entry process. A paper abstraction tool to collect data at the point of care for subsequent entry into Compass PTN Portal is also available in the Compass PTN Portal footer Manual Entry of Aggregate Measure Performance Data Practices with an EHR may provide aggregate clinical quality performance data reported from their EHR on a monthly basis. Practices will run clinical quality data reports from their EHR and then manually enter the aggregate clinician-level data, e.g., numerator, denominator, etc., for each measure via screens in Compass PTN Portal Quality Reporting Document Architecture (QRDA) III File Upload Practices may produce, through their EHR, Quality Reporting Document Architecture (QRDA) III (aggregate quality measure data) files and upload them securely through the Compass PTN Portal application. The QRDA file formats incorporate standard structures, enabling interoperability across EHR Page 47

48 vendors, allowing an organization's data to be efficiently collected, analyzed, and/or reported. A QRDA file upload screen will be available on the data submission site for practices with this capability. 7.3 Determining Your Practice's Data Submission Method(s) If your practice does not have an EHR or other method to determine your aggregate quality measure data, you must use the patient-level data entry option to report the measure data for the clinicians at your practice. If your practice has an EHR but you're unsure of what measure reporting capabilities it can provide, you may need to discuss this functionality with your IT department or EHR vendor to see what options are available for your practice. Your EHR does not need to be ONC-certified, however, it must be able to report data for the version of the measures that are part of the Compass PTN. If your EHR is not able to produce a QRDA III file per clinician per measure per month, perhaps it can provide an Excel dump of the data that you could then manipulate and aggregate to produce the data that is needed for entry into Compass PTN Portal. Compass PTN Portal is flexible in that in the next release you will be able to select your data submission method per clinician per measure per month. For example, if your EHR is able to produce a QRDA III file for only one of the measures, but can produce a report of aggregate data for another measure, you could submit data for the first measure via QRDA III file upload, and submit data for the second measure via manual entry of the aggregate data. You will also be able to modify your selected data submission methods each month. Until the next release, you will only be able to enter patient-level data. The ability to submit data via the aggregate data manual entry screens or via QRDA III file upload will be provided in the next few months. Page 48

49 8 Patient-Level Quality Measure Data Submission 8.1 Overview The patient-level data entry portion of the Compass PTN Portal provides clinical performance measurement results for the Compass PTN quality measures. In addition, the patient-level data entry portion of Compass PTN Portal integrates measure results with tools to assist you in identifying areas for quality improvement, as well as functionality which allows practices to easily identify care opportunities for patients. Some of the main features of patient-level data entry in Compass PTN Portal include: Improve outcomes for an individual patient Manage the practice s population in regards to preventive care and chronic illness Monitor provider/practice performance related to patient outcomes Compass PTN Portal is designed to enable a practice to hit the ground running jump start the move from paper to an electronic environment, report data for clinical, administrative and patient use and empower improvement initiatives. Key features include: Data entry of patient demographics, diagnoses, office visits, vitals, medications, clinical procedures, lab test results, and allergies Measure Status table on each patient screen that displays real-time adherence to measures, with a color-coded system to alert practices if the patient is not meeting the standards/goals 8.2 Frequency of Data Entry The expectation for practices participating in the Compass PTN is that all quality measure data for a particular reporting month be submitted in Compass PTN Portal by the 15th of the following month. For example, all quality measure data for March 2016 should be entered in Compass PTN Portal no later than April 15, Each practice submitting patient-level data will have to determine the data entry workflow that works the best within their practice workflow, whether entry into Compass PTN Portal is done daily, weekly, monthly, or on some other schedule. 8.3 Data Abstraction Worksheet A data abstraction worksheet (fillable/printable.pdf document) is being provided for practices who want to record data for a single patient at a time prior to entering the data into Compass PTN Portal. For example, as a possible workflow a practice may decide that a nurse or medical assistant complete a worksheet manually for a patient immediately following the patient's visit, and then provide the worksheets to the person identified as the practice's primary point of contact for Compass PTN who then enters the data into Compass PTN Portal at the end of the day or end of the month. Page 49

50 The data abstraction worksheet is organized to mimic the entry of the data into Compass PTN Portal. It identifies which data points are necessary for each measure so that you'll only have to record the data for the measure(s) that your practice is collecting and submitting. You may collect and enter more clinical data in Compass PTN Portal for your own sake if you'd like, however, the data needed for the specific Compass PTN measures is required at a minimum. A link to the data abstraction worksheet is located in the footer of the Compass PTN Portal application for practices to download and utilize if it will help them. 8.4 Sampling As patients are seen by your clinicians on a given day, you will identify which of those patients have the conditions/diagnoses that are applicable to the measure(s) you are reporting and record the pertinent data for those patients within Compass PTN Portal. The Compass PTN prefers that practices enter and submit data for all patients within the population of the measure(s) they are reporting. However, if the reporting burden is too high for your practice due to the volume of patients or lack of resources available to enter the data, you may perform a 50% sampling of patients for reporting. The sampling should be completely random, e.g., every other patient seen with that condition per day, or a random selection of 50% of the patients seen with that condition within a week or month, whichever method best fits with the workflow of entry that your practice has decided works best for you. 8.5 Compass PTN Portal Instructions for Patient-Level Data Entry The Manage Patient-Level Measures option in the What Do You Want to Do? box on the Home screen allows you to view a practice's measures status, as well as access and enter patient data. You may view a Practice's dashboard by looking up a practice, or you may also search for a patient, add a new patient, edit existing patients by adding visits and elements to their records, and view care opportunity reports. To begin click on the Manage Patient-Level Measures option on the Compass PTN Portal Home screen Provider Lookup The Provider Lookup will allow individual practices to view their measures dashboard. To view a practice's measures dashboard select the Provider Lookup link in the upper, left corner of the screen. Page 50

51 Figure 47. Provider Lookup Link After selecting the link a Provider Lookup box will appear. In this box select the practice(s) you wish to view by selecting the checkbox next to their name(s). Once you have selected your practice name(s), click the Done button in the bottom, right corner of the pop-up box. You can also choose to filter the list by entering a practice name in the Provider Title search box. Figure 48. Provider Lookup Filter by Provider Title After selecting the Done button, you will be directed to a measure dashboard for the practice(s) you selected. This dashboard allows the user to view their Care Opportunities report and Measure Status for all patients who meet the criteria to be included in each Compass PTN measure denominator. (replace sp) Page 51

52 Figure 49. Patient-Level Data Entry - Measures Dashboard The dashboard displays the following columns: Measure Displays the measure name in a gray row with the practice name(s) below in a white row. Status Displays a bar graph of how many patients are passing or failing the measure Population Count Displays the total number of patients that met the criteria to be included in the measure denominator. Excluded Count Displays the number of patients that met the population criteria to be included in the measure denominator, but were excluded due to clinical reasons or other reasons indicated by the measure specifications. Now Displays an indicator related to the current potential need for care opportunities for each measure. If the practice s measure status for a measure is 80 percent or greater a green checkmark will appear in this column for that measure s row and indicate that the practice is Page 52

53 meeting the threshold for that measure. If the measure status for a measure is less than 80 percent a red triangle with exclamation mark will appear in this column for that measure s row and indicates that there are care opportunities that need attention Measure Status In the Status section of the Measure Dashboard there is a status bar for each individual measure. The status bar illustrates how many patients are passing or failing the measure criteria. The green status bar will indicate the number of passing patients and a red status bar will indicate those patients that are not meeting criteria. You can click on the status bar to view the names of the patients who are passing or failing the measure. Clicking on the green section will display only the patients that are passing and clicking on the red section will display only the patients that are not meeting the measure criteria. (replace sp) Page 53

54 View Patients View Passing Patients To view the patients passing a specific measure click on the green section of the status bar. (replace SP) Figure 50. Patient-Level Data Entry - Measures Dashboard Status Bar Figure 51. Patient-Level Data Entry - Measures Dashboard Passing Status Page 54

55 View Failing Patients To view the patients that are failing a specific measure click on the red section of the status bar. Figure 52. Patient-Level Data Entry - Measures Dashboard Failing Status The following screen will display. The measure name will appear in the Measure Name column, and the Opportunities column will indicate the opportunities for each of the patients that have failed the measure, to either pass the measure or to be excluded from the measure if applicable. Figure 53. Patient-Level Data Entry - Measures Dashboard Breakdown of Failing Patients Page 55

56 View Excluded Patients To view the patients excluded from the denominator count click on the blue number link in the excluded column. Figure 54. Patient-Level Data Entry - Measures Dashboard Excluded Count The following screen will display. The measure name will appear in Measure Name column, and the various criteria that could have excluded the patient appear in the Opportunities column. Figure 55. Patient-Level Data Entry - Measures Dashboard Breakdown of Excluded Patients View Patient Details You can click on the link of a patient s name if you would like to review their record for additonal information on the measures that are applicable to the patient. (replace SP) Page 56

57 Figure 56. Patient-Level Data Entry - Measures Dashboard Drill-Down to Patient Once you are in the patient s record, their measure status will be displayed on the far right side of the screen. The measure name will appear as a blue link and will either have a green checkmark (indicating the patient is passing the measure), red triangle with exclamation point in the center of it (indicating the patient is failing the measure), or a black circle with a line through it (indicating the patient is excluded from the measure). Figure 57. Measure Status on Patient Summary Screen To view detailed instructions for a specific measure, select the blue measure name link. Page 57

58 Figure 58. Measure Status Link to Measure Details Instructions for viewing a patient s measure status can be found in the Patient Summary Screen section under Measure Status Add New Patient To add a new patient, select the Add New Patient button in the upper right corner of the screen. Figure 59. Patient-Level Data Entry - Add New Patient Link You will see a blank Patient Demographic Entry screen. Input the Patient Demographic information. The * fields are required. Page 58

59 Figure 60. Add New Patient Screen Although not all fields on this screen are required, complete the following fields for the Compass PTN program as follows: Organization: All of the practices to which you have access are displayed in this drop-down. Select the practice applicable to your patient. Member ID: Enter an ID for the patient, whether this is the medical record ID or some other ID. First Name Last Name Birth Date Gender Page 59

60 Primary Provider: Although this field is not officially required in the Compass PTN Portal tool, it is required for the Compass PTN initiative. The clinician name selected here will be the clinician for whom the measure results for this patient are attributed. Start typing the name of the clinician, and a list to select from will be provided when at least three characters have been entered. Group Membership: Start typing the name of the practice that you selected in the Organization field. The name of the practice should display in a drop-down for you to then select, after at least three characters have been entered. Once complete, click the Submit button to view the patient s record, or Cancel to exit. Upon adding and submitting patient information the patient record will display. Select the Save Patient button to save the patient you entered. Figure 61. Patient Summary Screen - Save Patient Button NOTE: You must select Save Patient for information to be saved. If you do not select Save Patient and navigate away from this screen the patient information will be lost. Page 60

61 8.5.3 Search for a Patient To search for a patient select the Search for a patient button in the upper right corner of the screen. Figure 62. Patient-Level Data Entry - Search for a Patient Link Once on the search for a patient screen, you can search for a patient by first name, last name, birth date, and/or primary provider. Click on the blue patient name link next to the patient you would like to review. Figure 63. Patient-Level Data Entry - Patient Search Results Patient Summary Screen On the patient summary screen you have the ability to update patient demographics, Add/Edit Visits, Add/Edit Elements, View Patient s Measure Status, and View Patient s Clinical Summary Patient Demographics To view the patient demographic data, click on the pencil icon next to the patient s name. Page 61

62 Figure 64. Patient Summary Screen - Edit Patient Icon Within the demographics screen you have the ability to update the patient s demographic data. If you update the patient s information, click Submit. If you do not need to update the patient s information click Cancel to exit. Page 62

63 Figure 65. Edit Patient Details Screen Add Visit Within the patient s summary screen you have the ability to document a patient encounter/visit and the associated activities that occurred within that visit. Click on the Add Visit button at the top of the screen. Page 63

64 Figure 66. Patient Summary Screen - Add Visit Button You will see a blank visit screen. Input visit information in the upper section of the screen. The * fields are required. Figure 67. Add Visit Screen NOTE: Start of Service date is the actual date of the visit/encounter. Page 64

65 Throughout the application in the fields that ask for a clinical code, such as the Visit Code field seen below, you can look up the codes by entering the first few digits of the code. You can also search for the codes by description; enter at least the first three characters of the word you are searching for and a list of code options will appear. The selected code will display in the field. If you select the wrong code and need to update it, select the X button at the end of the field. Figure 68. Add Visit Screen - Edit Field Button Selecting the X button will remove the current information, allowing you to update the field. Page 65

66 Figure 69. Add Visit Screen - Clinical Code Search Within the Add Visit screen, there are tabs where you can enter the patient s vitals, labs, allergies, diagnoses, immunizations, medications, and procedures that were completed during that visit. Each of the tabs is detailed below. Page 66

67 Figure 70. Add Visit Screen - Clinical Topic Tabs Vitals Tab Quick entry fields are provided for four common vital elements: standing height, body weight, systolic blood pressure and diastolic blood pressure. You can quickly enter these items by entering a date and a result. For any other vital elements you want to add, select the plus sign (+) icon on the right side of the screen. The following screen will display. Figure 71. Add Vitals Screen Input vital information. The * fields are required. Once information has been added select Submit. If you do not want to submit the changes select the Cancel button. Figure 72. Add Vitals Screen - Cancel and Submit Buttons Page 67

68 After selecting Submit you will be directed back to the Visit screen. The vital element you just added will be displayed. Select the Submit button to return to the patient summary screen, or select another tab to enter further clinical data for the visit. Figure 73. Vitals Tab - Vitals Listing To edit a Vital element that you manually created, select the pencil icon,, next to the element's name. The entry screen is displayed, allowing you to edit any of the fields. When finished, select Submit. If you do not want to submit the changes select the Cancel button. Page 68

69 Labs Tab To add a Lab to the patient s record select the Labs tab. Quick entry fields are provided for six common lab elements: HgbA1c, microalbumin/creatine ratio, total cholesterol, triglycerides, LDL, and HDL. You can quickly enter these items by entering a date and a result. For any other lab elements you want to add, select the plus sign (+) icon on the right side of the screen. The following screen is displayed. Figure 74. Add Lab Screen Input Lab information. The * fields are required. Once information has been added select Submit. If you do not want to submit the changes select the Cancel button. Figure 75. Add Lab Screen - Cancel and Submit Buttons Page 69

70 After selecting Submit you will be directed back to the Visit screen with the Vitals tab shows. Re-select the Labs tab. The element you added will be displayed on the screen. Select the Submit button to return to the patient summary screen, or select another tab to enter further clinical data for the visit. Figure 76. Labs Tab - Lab Listing To edit a Lab element that you manually created, select the pencil icon,, next to the element's name. The entry screen is displayed, allowing you to edit any of the fields. When finished, select Submit. If you do not want to submit the changes select the Cancel button Allergies Tab To add an allergy to the patient s record select the Allergies tab. To add a new allergy, select the plus sign (+) icon on the right side of the screen. The following screen is displayed. Page 70

71 Figure 77. Add Allergy Screen Input Allergy information. The * fields are required. Once information has been added select Submit. If you do not want to submit the changes select the Cancel button. Figure 78. Add Allergy Screen - Cancel and Submit Buttons After selecting Submit you will be directed back to the Visit screen with the Vitals tab shows. Re-select the Allergies tab. The element you added will be displayed on the screen. Select the Submit button to return to the patient summary screen, or select another tab to enter further clinical data for the visit. Page 71

72 Figure 79. Allergies Tab - Allergy Listing To edit an Allergy element that you manually created, select the pencil icon,, next to the element's name. The entry screen is displayed, allowing you to edit any of the fields. When finished, select Submit. If you do not want to submit the changes select the Cancel button Diagnoses Tab To add a diagnosis to the patient s record select the Diagnoses tab. To add a new diagnosis, select the plus sign (+) icon on the right side of the screen. The following screen is displayed. Figure 80. Add Diagnosis Screen Input Diagnosis information. The * fields are required. Once information has been added select Submit. If you do not want to submit the changes select the Cancel button. NOTE: Identification Date is not shown as being required, however, it is a required element. This will be fixed in a future release of Compass PTN Portal. Page 72

73 Figure 81. Add Diagnosis Screen - Cancel and Submit Buttons After selecting Submit you will be directed back to the Visit screen with the Vitals tab shows. Re-select the Diagnoses tab. The element you added will be displayed on the screen. Select the Submit button to return to the patient summary screen, or select another tab to enter further clinical data for the visit. Figure 82. Diagnoses Tab - Diagnoses Listing To edit a Diagnosis element that you manually created, select the pencil icon,, next to the element's name. The entry screen is displayed, allowing you to edit any of the fields. When finished, select Submit. If you do not want to submit the changes select the Cancel button Immunizations Tab To add an immunization to the patient s record select the Immunizations tab. To add a new immunization, select the plus sign (+) icon on the right side of the screen. The following screen is displayed. Page 73

74 Figure 83. Add Immunization Screen Input immunization information. The * fields are required. Once information has been added select Submit. If you do not want to submit the changes select the Cancel button. Figure 84. Add Immunization Cancel and Submit Buttons After selecting Submit you will be directed back to the Visit screen with the Vitals tab shows. Re-select the Immunizations tab. The element you added will be displayed on the screen. Select the Submit button to return to the patient summary screen, or select another tab to enter further clinical data for the visit. Page 74

75 Figure 85. Immunizations Tab - Immunization Listing To edit an Immunization element that you manually created, select the pencil icon,, next to the element's name. The entry screen is displayed, allowing you to edit any of the fields. When finished, select Submit. If you do not want to submit the changes select the Cancel button Medications Tab To add a medication to the patient s record select the Medications tab. To add a new medication, select the plus sign (+) icon on the right side of the screen. The following screen is displayed. Page 75

76 Figure 86. Add Medications Screen Input medication information. The * fields are required. Once information has been added select Submit. If you do not want to submit the changes select the Cancel button. Figure 87. Add Medications Screen - Cancel and Submit Buttons After selecting Submit you will be directed back to the Visit screen with the Vitals tab shows. Re-select the Medications tab. The element you added will be displayed on the screen. Select the Submit button to return to the patient summary screen, or select another tab to enter further clinical data for the visit. Figure 88. Medications Tab - Medication Listing Page 76

77 To edit a Medication element that you manually created, select the pencil icon,, next to the element's name. The entry screen is displayed, allowing you to edit any of the fields. When finished, select Submit. If you do not want to submit the changes select the Cancel button Procedures Tab To add a procedure to the patient s record select the Procedures tab. To add a new procedure, select the plus sign (+) icon on the right side of the screen. The following screen is displayed. Figure 89. Add Procedure Screen Input procedure information. The * fields are required. Once information has been added select Submit. If you do not want to submit the changes select the Cancel button. Page 77

78 Figure 90. Add Procedure Screen - Cancel and Submit Buttons After selecting Submit you will be directed back to the Visit screen with the Vitals tab shows. Re-select the Procedures tab. The element you added will be displayed on the screen. Select the Submit button to return to the patient summary screen, or select another tab to enter further clinical data for the visit. Figure 91. Procedures Tab - Procedure Listing To edit a Procedure element that you manually created, select the pencil icon,, next to the element's name. The entry screen is displayed, allowing you to edit any of the fields. When finished, select Submit. If you do not want to submit the changes select the Cancel button Edit Visit Data To edit a visit click on the edit icon next to the visit that needs to be updated. Figure 92. Patient Summary Screen - Edit Visit Icon Page 78

79 After selecting the edit icon, the information from the visit will open. You have the ability to edit all fields in the edit screen. If the field is gray, you can update it by first selecting the X button at the end of the field. Figure 93. Edit Visit Screen - Delete Code Button Selecting the X button will remove the current information, allowing you to update the field. Each of the tabs within the visit (Vitals, Labs, Allergies, Diagnoses, Immunizations, Medications, and Procedures) can also be updated as needed. For example if you would like to add a procedure to the visit, select the Procedure tab and click on the plus sign located in the right corner of that tab. Page 79

80 Figure 94. Procedures Tab - Add Procedure Button A screen to enter your procedure information is displayed. Figure 95. Add Procedure Screen Once you have entered the Procedure information, click the Submit button in the bottom right corner of the screen or Cancel to exit. After selecting Submit you will be directed back to the Add/Edit Visit screen, defaulted to the Vitals tab. Page 80

81 Figure 96. Visit Screen - Cancel and Submit Buttons Note: Once you have updated all information for this patient s visit, click the Submit button in the bottom right corner of the screen or Cancel to exit. You must select Save Patient for information to be saved. If you do not select Save Patient and navigate away from this screen the patient information will be lost Add Element Figure 97. Patient Summary Screen - Save Patient Button and Link Page 81

82 It is possible within Compass PTN Portal to add individual clinical elements for a patient without having to add an actual visit record. To add an element to a patient s record select the button with a plus sign (+) at the top of the screen, to the left of the Add Visit button. Figure 98. Patient Summary Screen - Add Element Button There are eight elements you have the ability to add; Allergy, Exclusion, Diagnosis, Immunization, Lab, Medication, Procedure, and Vital. Within each element screen you will have the ability to look up the vital, lab, allergy, diagnosis, immunization, medication, procedure, and exclusion codes by entering the first few digits of the code. You can also search for the codes by description; enter at least the first three characters of the word you are searching for and a list of code options will appear. Page 82

83 Add Allergy Element To add an allergy to the patient s record select Allergy from the Add Element drop down. The following screen will display. Figure 99. Patient Summary Screen - Add Allergy Element Button Figure 100. Add Allergy Element Screen Input allergy information. The * fields are required. Once information has been added select Submit. If you do not want to submit the changes select the Cancel button. Figure 101. Add Allergy Element Screen - Cancel and Submit Buttons Page 83

84 After selecting Submit you will be directed back to the patient s summary screen. The allergy element that you entered is displayed on the screen. Select the Save Patient button to save the allergy you entered. NOTE: You must select Save Patient for information to be saved. If you do not select Save Patient and navigate away from this screen the patient information will be lost Add Diagnosis Element To add a Diagnosis to the patient s record select Diagnosis from the Add Element drop down. The following screen will display. Figure 102. Patient Summary Screen - Add Diagnosis Element Figure 103. Add Diagnosis Element Screen Input Diagnosis information. The * fields are required. The Identification Date should also be required. Once information has been added select Submit. If you do not want to submit the changes select the Cancel button. Page 84

85 NOTE: Even though the Identification Date field does not have a asterisk next to it to indicate that it is required, this field is required. This will be fixed in a future release. Figure 104. Add Diagnosis Element Screen - Cancel and Submit Buttons After selecting Submit you will be directed back to the patient s summary screen. The diagnosis element you just added will be displayed. Select Save Patient button to save the diagnosis you entered. NOTE: You must select Save Patient for information to be saved. If you do not select Save Patient and navigate away from this screen the patient information will be lost. Figure 105. Patient Summary Screen - Diagnosis Element Added Add Immunization Element To add an Immunization to the patient s record select Immunization from the Add Element drop down. Page 85

86 Figure 106. Patient Summary Screen - Add Immunization Element The following screen will display. Figure 107. Add Immunization Element Screen Input Immunization information. The * fields are required. Once information has been added select Submit. If you do not want to submit the changes select the Cancel button. Figure 108. Add Immunization Element Cancel and Submit Buttons Page 86

87 After selecting Submit you will be directed back to the patient s summary screen. The Immunization element you just added will display. Select the Save Patient button to save the immunization you entered. Figure 109. Patient Summary Screen - Immunization Element Added NOTE: You must select Save Patient for information to be saved. If you do not select Save Patient and navigate away from this screen the patient information will be lost. Page 87

88 Add Lab Element To add a Lab to the patient s record select Lab from the Add Element drop-down box. The following screen will display. Figure 110. Patient Summary Screen - Add Lab Element Figure 111. Add Lab Element Screen Input Lab information. The * fields are required. Once information has been added select Submit. If you do not want to submit the changes select the Cancel button. Page 88

89 Figure 112. Add Lab Element Screen - Cancel and Submit Buttons After selecting Submit you will be directed back to the patient s summary screen. The lab element that you added will be displayed on the screen. Select the Save Patient button to save the lab you entered. NOTE: You must select Save Patient for information to be saved. If you do not select Save Patient and navigate away from this screen the patient information will be lost Add Medication Element To add a Medication to the patient s record select Medication from the Add Element drop down. The following screen will display. Figure 113. Patient Summary Screen - Add Medication Element Page 89

90 Figure 114. Add Medication Element Screen Input Medication information. The * fields are required. Once information has been added select Submit. If you do not want to submit the changes select the Cancel button. Figure 115. Add Medication Element Screen - Cancel and Submit Buttons After selecting Submit you will be directed back to the patient s summary screen. The medication you added will display on this screen. Select Save Patient button to save the medication you entered. Page 90

91 NOTE: You must select Save Patient for information to be saved. If you do not select Save Patient and navigate away from this screen the patient information will be lost. Figure 116. Patient Summary Screen - Medication Element Added Add Procedure Element To add a Procedure to the patient s record select Procedure from the Add Element drop-down. The following screen will display. Figure 117. Patient Summary Screen - Add Procedure Element Page 91

92 Figure 118. Add Procedure Element Screen Input Procedure information. The * fields are required. Once information has been added select Submit. If you do not want to submit the changes select the Cancel button. Figure 119. Add Procedure Element Screen - Cancel and Submit Buttons After selecting Submit you will be directed back to the patient s summary screen. The procedure you just added will be displayed. Select the Save Patient button to save the procedure you entered. NOTE: You must select Save Patient for information to be saved. If you do not select Save Patient and navigate away from this screen the patient information will be lost. Page 92

93 Figure 120. Patient Summary Screen - Procedure Element Added Add Vital Element To add a Vital to the patient s record select Vital from the Add Element drop down. The following screen will display. Figure 121. Patient Summary Screen - Add Vital Element Page 93

94 Figure 122. Add Vital Element Screen Input vital information. The * fields are required. Once information has been added select Submit. If you do not want to submit the changes select the Cancel button. Figure 123. Add Vital Element Screen - Cancel and Submit Buttons After selecting Submit you will be directed back to the patient s summary screen. The vital element you just added will be displayed. Select Save Patient button to save the vital you entered. NOTE: You must select Save Patient for information to be saved. If you do not select Save Patient and navigate away from this screen the patient information will be lost Adding Exclusions Figure 124. Patient Summary Screen - Vital Element Added Page 94

95 Sometimes clinical quality measures include specific diagnoses or medications as exclusions. Entering those codes on the appropriate tab within a visit will then be counted as an Exclusion and remove the patient from the Denominator of the measure. However, other measures may have a specific Exclusion code to be used to exclude the patient from a measure. For example, the 'Appropriate Treatment for Children with Upper Respiratory Infection (URI)' measure has an exclusion code G Patient prescribed or dispensed antibiotic for documented medical reason(s). This kind of code is entered differently than other codes. To add an Exclusion code to the patient s record select Exclusion from the Add Element drop-down. The following screen is displayed. Figure 125. Patient Summary Screen - Add Exclusion Element Figure 126. Add Exclusion Element Screen Input Exclusion information. The * fields are required. Once information has been added select Submit. If you do not want to submit the changes select the Cancel button. Page 95

96 Figure 127. Add Exclusion Element Screen - Cancel and Submit Buttons After selecting Submit you will be directed back to the patient s summary screen. The exclusion you entered is displayed on the screen. Select the Save Patient button to save the exclusion you entered. NOTE: You must select Save Patient for information to be saved. If you do not select Save Patient and navigate away from this screen the patient information will be lost. Figure 128. Patient Summary Screen - Exclusion Element Added Edit Element To edit an element that has been entered outside of a visit/encounter, click on the edit icon next to the element that needs to be updated. Page 96

97 Figure 129. Patient Summary Screen - Edit Element Icon After selecting the edit icon, the information for that element will open. You have the ability to edit all fields in the edit screen. If the field is gray, you can update it by first selecting the X button at the end of the field. Once the field is edited, and the user selects Submit the previous data will be replaced with the new value. Figure 130. Edit Vital Element Screen - Delete Code Button Selecting the X button will remove the current information, allowing you update the field. Page 97

98 Figure 131. Edit Vital Element Screen - Code Deleted Once you have updated the information for the patient s element click the Submit button in the bottom right corner of the screen. After selecting Submit you will be directed back to the patient s summary screen. Select the Save Patient button to save the changes you entered. NOTE: You must select Save Patient for information to be saved. If you do not select Save Patient and navigate away from this screen the patient information will be lost Measure Status Figure 132. Edit Vital Element Screen - Cancel and Submit Buttons The patient s measure status will be displayed on right side of the patient s summary screen. The measure name will appear as a blue link and will either have a green checkmark or red triangle containing an exclamation point. Page 98

99 Figure 133. Patient Summary Screen - Measure Status Column To view detailed instructions for a specific measure, select the measure name. Figure 134. Patient Summary Screen - Selectable Measure Name Link After selecting the measure name link the measure criteria will display. For most measures the following kind of screen displays. Page 99

100 Figure 135. Measure Criteria List Example for Heart Failure Beta-Blocker Therapy Measure A green checkmark displayed to the left of the measure criteria indicates that the patient has met the criteria. A red triangle containing an exclamation point displayed to the left of the measure criteria indicates that the patient has not met the criteria. For the Diabetes measure the following screen displays. Figure 136. Measure Criteria Example for Diabetes A1c Poor Control Measure Page 100

101 This screen contains a section for each of measure criteria, showing the codes for each criteria. Each of the criteria sections has a link you can select to be taken directly to a screen to enter data for that criteria Figure 137. Measure Criteria Example with Link to Enter Patient Diagnosis After selecting the link you will be directed to the element screen you selected to update. For instance if you select the Enter patient diagnosis link, you will be directed to the Add Diagnosis screen. When done reviewing the instructions for the selected measure, click the Close button in the bottom right corner of the screen. Page 101

102 Figure 138. Measure Criteria Example - Close Button If the patient does not meet criteria to be included in any measure's denominator, the following message will display in the Measure Status section. Figure 139. Measure Status Unavailable Clinical Summary To view the Patient s Clinical Summary, select the Clinical Summary link under the Patient s name on the left side of the Patient Summary screen. Figure 140. Patient Summary Screen - Clinical Summary Link The Clinical Summary will include the relevant medical data from the most recent visits for the selected patient. Page 102

103 Figure 141. Clinical Summary 9 Custom Measures 9.1 Creating Custom Measures The Compass PTN portal allows practices to create custom measures that our outside of the core measures that have been chosen by the Compass PTN. Currently the Compass PTN only allows users to create custom measures at the practice level. Custom measures will only be tracked internally at the practice level, there will be no comparison data for practices that chose to create custom measures. Page 103

104 9.1.1 Navigation to Create Custom Measures Participants of the Compass PTN portal can navigate to the custom measure by following the below steps. 1. Login in as a Practice admin or a QI advisor 2. Select the Home button from the top left corner 3. Select the Enter Aggregate Data for My Practice Button 4. After selecting the Enter Aggregate Data for My practice users will need to choose their practice from the left side of the practice data dashboard 5. After selecting your practice, the dashboard will expand and an option for selecting Add Custom Measure will appear See Figure 139 a. Important Notes: Custom Measure will only be populated for months that are on or after the reporting period from the Dashboard. b. If users need to have previous month populated with custom measure, PTN participants will need to change the reporting period month by selecting the calendar icon. Figure 142. Custom Measure Selection Filling out Custom Measure Form Page 104

105 Once users have selected the Add Custom Measure button, PTN participants will be directed to the custom measure form. The form will allow PTN participants to define the custom measure they will be reporting on for the Compass PTN. All text areas need to be filled out with the defined population that will be within the measure. Figure 143. Custom Measure Form Figure 140 displays the custom measure form from the Compass PTN portal. If the custom measure contains any exclusion or exception by checking the appropriate check box. This will display an additional text field, which will allow users to define the exclusion/exception population for the custom measure. Important Note: The custom measure form can only be filled out one time. If users make a mistake on the form the only way to correct the form is to delete the form and start over. Custom Measures cannot be updated with the upload data option using an excel spreadsheet The Compass PTN portal will validate if a custom measure of the same name is already present on that specific practice. If users are wanting to create two measures with the same name, the measure name will need to be changed slightly to save the form Reporting on Custom Measure Once the custom measure form has been filled out and saved. The new measure will appear at the bottom of the Practice Data Dashboard. Once on the dashboard the measure will act like any of the core Page 105

106 measures. The custom measure will display in a different color on the dashboard to indicate that the measure is not part of the core measure of the Compass PTN. Figure 144. Custom Measure Removing Custom Measures Practices will have the option to remove custom measure from their dashboard. By selecting the trash can icon next to the custom measure, this will remove the custom measure from the practice. However, once the measure has been removed from the dashboard the data will no longer show up on the Compass PTN run charts for the individual practices. Page 106