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Establish, implement, and maintain an Electronic Health Records measurement metrics program.


CONTROL ID
06221
CONTROL TYPE
Establish/Maintain Documentation
CLASSIFICATION
Preventive

SUPPORTING AND SUPPORTED CONTROLS



This Control directly supports the implied Control(s):
  • Establish, implement, and maintain a compliance monitoring policy., CC ID: 00671

This Control has the following implementation support Control(s):
  • Report on the percentage of unique patients who had at least one medication entered using the Computerized Provider Order Entry system., CC ID: 06222
  • Report on the percentage of unique patients who have diagnoses recorded as structured data into the current and active diagnoses problem list., CC ID: 06223
  • Report on the percentage of permissible prescriptions that are transmitted electronically., CC ID: 06224
  • Report on the percentage of unique patients who have at least one entry recorded as structured data into the active medication list., CC ID: 06225
  • Report on the percentage of unique patients who have at least one entry recorded as structured data into the active medication allergy list., CC ID: 06226
  • Report on the percentage of unique patients who have demographics recorded as structured data., CC ID: 06227
  • Report on the percentage of unique patients over the age of 2 who have their height, weight, and blood pressure recorded as structured data., CC ID: 06228
  • Report on the percentage of unique patients over the age of 13 who have their smoking status recorded as structured data., CC ID: 06229
  • Report on the percentage of patients who are given an electronic copy of their Individually Identifiable Health Information not later than three business days after Individually Identifiable Health Information is requested., CC ID: 06230
  • Report on the percentage of patients who are given clinical summaries not later than three business days after a physician office visit., CC ID: 06231
  • Report on the percentage of lab test results that are incorporated into the Electronic Health Records as structured data., CC ID: 06232
  • Report on the percentage of patients sixty-five years of age or older or five years of age or younger who were sent a reminder., CC ID: 06233
  • Report on the percentage of unique patients who are given electronic access to their Individually Identifiable Health Information not later than four business days after their Individually Identifiable Health Information is updated., CC ID: 06234
  • Report on the percentage of unique patients who are given patient-specific education resources., CC ID: 06235
  • Report on the percentage of medication reconciliations that are performed if a patient is received from another setting or healthcare provider., CC ID: 06236
  • Report on the percentage of summary of care records that are provided for transitions of care or referrals for patients who are transitioned or referred to another setting or healthcare provider., CC ID: 06237
  • Report on the percentage of patients who receive their discharge instructions if discharge instructions are requested., CC ID: 06238
  • Report on the percentage of patients 65 years of age or older who have an indication of advance directive status recorded as structured data., CC ID: 06239


SELECTED AUTHORITY DOCUMENTS COMPLIED WITH



  • Calculate each and every clinical quality measure for which it is presented for certification. (§ 170.315 (c) (2) (ii), 45 CFR Part 170 Health Information Technology Standards, Implementation Specifications, and Certification Criteria and Certification Programs for Health Information Technology, current as of January 2024)
  • Transmission to public health agencies—antimicrobial use and resistance reporting. Create antimicrobial use and resistance reporting information for electronic transmission in accordance with the standard specified in §170.205(r)(1). (§ 170.315 (f) (5) (iii) (B) (6), 45 CFR Part 170 Health Information Technology Standards, Implementation Specifications, and Certification Criteria and Certification Programs for Health Information Technology, current as of January 2024)
  • Taxpayer Identification Number. (§ 170.315 (c) (4) (iii) (A), 45 CFR Part 170 Health Information Technology Standards, Implementation Specifications, and Certification Criteria and Certification Programs for Health Information Technology, current as of January 2024)
  • National Provider Identifier. (§ 170.315 (c) (4) (iii) (B), 45 CFR Part 170 Health Information Technology Standards, Implementation Specifications, and Certification Criteria and Certification Programs for Health Information Technology, current as of January 2024)
  • Practice site address. (§ 170.315 (c) (4) (iii) (D), 45 CFR Part 170 Health Information Technology Standards, Implementation Specifications, and Certification Criteria and Certification Programs for Health Information Technology, current as of January 2024)
  • Automated measure calculation. For each Promoting Interoperability Programs percentage-based measure that is supported by a capability included in a technology, record the numerator and denominator and create a report including the numerator, denominator, and resulting percentage associated with eac… (§ 170.315 (g) (2), 45 CFR Part 170 Health Information Technology Standards, Implementation Specifications, and Certification Criteria and Certification Programs for Health Information Technology, current as of January 2024)
  • Automated numerator recording. For each Promoting Interoperability Programs percentage-based measure, technology must be able to create a report or file that enables a user to review the patients or actions that would make the patient or action eligible to be included in the measure's numerator. The… (§ 170.315 (g) (1), 45 CFR Part 170 Health Information Technology Standards, Implementation Specifications, and Certification Criteria and Certification Programs for Health Information Technology, current as of January 2024)
  • Match a patient visit or encounter to the trigger code based on the parameters of the trigger code table. (§ 170.315 (f) (5) (ii), 45 CFR Part 170 Health Information Technology Standards, Implementation Specifications, and Certification Criteria and Certification Programs for Health Information Technology, current as of January 2024)
  • Provider type in accordance with, at a minimum, the standard specified in § 170.207(r)(2). (§ 170.315 (c) (4) (iii) (C), 45 CFR Part 170 Health Information Technology Standards, Implementation Specifications, and Certification Criteria and Certification Programs for Health Information Technology, current as of January 2024)
  • Patient insurance in accordance with the standard specified in § 170.207(s)(2). (§ 170.315 (c) (4) (iii) (E), 45 CFR Part 170 Health Information Technology Standards, Implementation Specifications, and Certification Criteria and Certification Programs for Health Information Technology, current as of January 2024)
  • Patient sex in accordance with the version of the standard specified in § 170.207(n)(2). (§ 170.315 (c) (4) (iii) (G), 45 CFR Part 170 Health Information Technology Standards, Implementation Specifications, and Certification Criteria and Certification Programs for Health Information Technology, current as of January 2024)
  • Patient race and ethnicity in accordance with, at a minimum, the version of the standard specified in § 170.207(f)(3). (§ 170.315 (c) (4) (iii) (H), 45 CFR Part 170 Health Information Technology Standards, Implementation Specifications, and Certification Criteria and Certification Programs for Health Information Technology, current as of January 2024)
  • Patient problem list data in accordance with, at a minimum, the version of the standard specified in § 170.207(a)(1). (§ 170.315 (c) (4) (iii) (I), 45 CFR Part 170 Health Information Technology Standards, Implementation Specifications, and Certification Criteria and Certification Programs for Health Information Technology, current as of January 2024)
  • Calculate each and every clinical quality measure for which it is presented for certification. (§ 170.315 (c) (2) (ii), 45 CFR Part 170, Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, current as of July 14, 2020)
  • Patient problem list data in accordance with, at a minimum, the version of the standard specified in §170.207(a)(4). (§ 170.315 (c) (4) (iii) (I), 45 CFR Part 170, Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, current as of July 14, 2020)
  • Patient sex in accordance with the version of the standard specified in §170.207(n)(1). (§ 170.315 (c) (4) (iii) (G), 45 CFR Part 170, Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, current as of July 14, 2020)
  • Patient insurance in accordance with the standard specified in §170.207(s)(1). (§ 170.315 (c) (4) (iii) (E), 45 CFR Part 170, Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, current as of July 14, 2020)
  • Transmission to public health agencies—antimicrobial use and resistance reporting. Create antimicrobial use and resistance reporting information for electronic transmission in accordance with the standard specified in §170.205(r)(1). (§ 170.315 (f) (5) (iii) (B) (6), 45 CFR Part 170, Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, current as of July 14, 2020)
  • Taxpayer Identification Number. (§ 170.315 (c) (4) (iii) (A), 45 CFR Part 170, Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, current as of July 14, 2020)
  • National Provider Identifier. (§ 170.315 (c) (4) (iii) (B), 45 CFR Part 170, Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, current as of July 14, 2020)
  • Patient race and ethnicity in accordance with, at a minimum, the version of the standard specified in §170.207(f)(2). (§ 170.315 (c) (4) (iii) (H), 45 CFR Part 170, Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, current as of July 14, 2020)
  • Provider type in accordance with, at a minimum, the standard specified in §170.207(r)(1). (§ 170.315 (c) (4) (iii) (C), 45 CFR Part 170, Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, current as of July 14, 2020)
  • Practice site address. (§ 170.315 (c) (4) (iii) (D), 45 CFR Part 170, Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, current as of July 14, 2020)
  • Automated measure calculation. For each Promoting Interoperability Programs percentage-based measure that is supported by a capability included in a technology, record the numerator and denominator and create a report including the numerator, denominator, and resulting percentage associated with eac… (§ 170.315 (g) (2), 45 CFR Part 170, Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, current as of July 14, 2020)
  • Automated numerator recording. For each Promoting Interoperability Programs percentage-based measure, technology must be able to create a report or file that enables a user to review the patients or actions that would make the patient or action eligible to be included in the measure's numerator. The… (§ 170.315 (g) (1), 45 CFR Part 170, Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, current as of July 14, 2020)
  • Consume and maintain a table of trigger codes to determine which encounters may be reportable. (§ 170.315 (f) (5) (i), 45 CFR Part 170, Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, current as of July 14, 2020)
  • Match a patient visit or encounter to the trigger code based on the parameters of the trigger code table. (§ 170.315 (f) (5) (ii), 45 CFR Part 170, Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, current as of July 14, 2020)