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	James L. Holly, M.D.

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Medical Home - Pre-visit Evaluation

For recognition as a Tier 3 Patient-Centered Medical home, NCQA identifies 9 Standards, in which there are a total of 30 elements, containing 183 data points. Standard 2 is entitled "Patient Tracking and Registry Functions." Of a total of 100 points available for fulfillment of all 9 Standards, this one standard, which has six elements (20% of the total 30) accounts for 21 or almost 25% of the total points available.

Element F of Standard 2 is entitled "Use of System for Population Management". The details state:

"The practice uses electronic information to generate lists of patients and take action to remind patients or clinicians proactively of services needed, as follows:

Patients needing pre-visit planning (obtaining tests prior to visit, etc.)
Patients needing clinician review or action.
Patients on a particular mediation
Patients needing reminds for preventive care.
Patients needing reminders for specific tests.
Patients needing reminders for follow-up visits such as for a chronic condition.
Patients who might benefit from care management support."

In fulfilling these, SETMA designed and executed the COGNOS project. One part of this project involves every provider, every day receiving a list of patients scheduled for that day with a review of their preventive health needs, of their screening testing needs and of other care they need in order to meet national quality standards in their care. The second step in this part of the project is that after the day is over, another electronic audit will be done to see if the preventive health needs, screening health need and quality standards needs for each patient have been met.

Other parts of Element F will be met in other ways, but all will be done.

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