Update on Electronic Medical Record System

TMH is on the way to having a complete electronic medical record (EMR) system.  We have recently undergone conversion from paper progress notes to electronic notes, aka PowerNotes, throughout the hospital.  Thanks to everyone involved in this transition, from the physicians and other providers who are using the system to the unit secretaries who helped corral the paper. We continue to build on...
read more

Physician Partners Advisory Meeting Highlights

The Tallahassee Memorial Hospital Physician Partners (TMHPP) Advisory Committee was formed this November 2012. The members of this committee represent the TMH Physician Partners. TMHPP is currently composed of over 125 primary and specialty physicians providing health care in over 4 north Florida counties. TMHPP’s composition includes physicians in the Emergency Center, Cancer and...
read more

Physician Quality Reporting System

The Physician Quality Reporting System (Physician Quality Reporting or PQRS) is a reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals. The program provides an incentive payment to practices with eligible professionals  who satisfactorily report data on quality measures for covered Physician...
read more

TMH Physician Partners Advisory Committee

Sarmed Ashoo, MD, Emergency Services Sam.ashoo@tmh.org 431-0755 office 445-0404 cell     Tim Broeseker, MD, TMH PP, Cancer & Hematology Specialists Tim.Broeseker@tmh.org Contact: Sonia Lee, Sonia.Lee@tmh.org 431-5360 office 431-0556 office 2 298-3412 pager 264-2162 cell Jeffrey Ferraro, MD, Behavioral Health Center Jeffrey.Ferraro@tmh.org Contact: Jan...
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Its time that you took your website to the next level.
Update on Electronic Medical Record System

TMH is on the way to having a complete electronic medical record (EMR) system.  We have recently undergone conversion from paper progress notes to electronic notes, aka PowerNotes, throughout the hospital.  Thanks to everyone involved in this transition, from the physicians and other providers who are using the system to the unit secretaries who helped corral the paper.

We continue to build on this knowledge and work on the templates needed to move other documents into the digital domain.  Please don’t hesitate to contact Clinical Informatics with any questions or concerns about this at 431-5585.

We are now enrolling any providers writing orders in the Women’s Pavilion to our Computerized Provider Order Entry (CPOE) classes. These classes start now and continue until go-live on February 26th, 2013.  After this date, all orders in the Women’s Pavilion will be placed directly in the computer and not on paper.  Please call as soon as possible to schedule your training.

In the meantime, many efforts are underway throughout the hospital to improve the utilization of our EMR.  These include our work towards implementing CareAware, which will allow our ICU vital signs to flow directly into the patient record.  Our IT department is also working to increase the memory on the system to support the many new users and uses of the EMR.

Day-to-day support for, and building of the system continues even as we add new projects to the schedule in anticipation of having full CPOE throughout TMH. Thank you for your assistance and patience as we go through this transition.
 

By: Randa Perkins, MD, Hospitalist, Executive Director of Medical Informatics

By: Dean Watson, MD, Chief Medical Officer

read more
Physician Partners Advisory Meeting Highlights

The Tallahassee Memorial Hospital Physician Partners (TMHPP) Advisory Committee was formed this November 2012. The members of this committee represent the TMH Physician Partners. TMHPP is currently composed of over 125 primary and specialty physicians providing health care in over 4 north Florida counties. TMHPP’s composition includes physicians in the Emergency Center, Cancer and Hematology, Behavorial Heath Center, Southern Medical Group, Clinical Genetics, Endocrinology, Hospitalists, Family Practice and Internal Medicine Residency faculty, General Surgery, Rehabilitation, Maternal-Fetal Medicine, Bariatric Center, Pain Center, Palliative Care, Obstetrical Midwifery Services, Marianna Cardiology, Lipid Center and the primary care clinics in Blountstown, Quincy, Wakulla, Monticello, Perry and Southwood.
   

Meeting Minute Highlights for November 2012

The initial goals of the Advisory Committee are to provide direction regarding the performance of its physicians and respective practices employed by or partnered with TMH through TMHPP.

  • Monitor the direction and performance of TMHPP
  • Assist in integration of TMH strategic plan with the Strategic and tactical direction of TMHPP
  • Medical informatics-practice tools and technologies
  • Local and national quality initiatives i.e. HCAHPS, MEANINGFUL USE, PQRI, AMA PCPI, NCQA
  • Regulatory Standards: Joint Commission
  • Recruitment and Marketing

Dr. Mahoney discussed his role as Chief Integration Officer as well as how the committee relates to the medical staff, MEC and the TMH Medical Staff Bylaws. Contact Dr. Mahoney directly at 431-5544 or mahoneysbooks@violinsandbows.com if you need additional information or clarification. Stephanie Derzypolski, Director of Program Development at TMH, joined the committee this February. Rob Moss, Executive Director of the Medical Outreach & Physician Services, has accepted an invitation to join the committee in March.

 

January 2013

1. Cindy Blair, Chief Improvement and Planning Officer met with the committee to outline how her department can assist each TMH Physician Partners office.

The group recommended that Dr. Mahoney, Dr. Ferraro, Ms. Blair and Rob Moss meet to make a recommendation to the Committee on those high volume quality parameters

that will be submitted for calendar year 2013. This recommendation will be e-mailed to Committee members for discussion, vote and approval.

2. The group also voted to have Rob Moss attend the February meeting to discuss updates and implementation schedules regarding Allscripts, EHR, the ability of existing information systems to assist the offices in assuring that mandated quality parameter data will be gathered and reported and an action plan with time lines for groups with expected delays and deficiencies.

3. Dr Mahoney discussed the importance of keeping all TMH-PP members informed and involved in this endeavor. He has requested that Warren Jones’s representative, Stephanie Derzypolski formulate an electronic newsletter that can be sent to all TMH-PP members.

The group requested that Stephanie Derzypolski be invited to join the permanent administrative staff of the TMH-PP Advisory Committee as a non-voting member.

4. The committee addressed areas of immediate review:

  • The primacy of the hospital’s inpatient acute care needs and financial support overwhelming the aspirations of TMH-PP and the future TMH strategic plans for TMH-PP.
  • The committee is in an embryonic stage with no lines of authority, finances, employees, structure or accountability. The TMH Board’s visions, goals, expectations and pathways towards a future successful implementation of TMH-PP are as yet undefined
  • Frustration at attempting to practice out-patient medicine efficiently and having a financially and professionally rewarding practice and a desirable family life. Making sure that TMH does not become merely the enforcer of CMS penalty-driven quality measures, but actually is the driver of a physician-hospital partnership transforming health care for the betterment of our citizens.

5. The Committee discussed current Committee composition.

Discussions about recruitment of other practices and specialty types ensued. Further actions deferred until separate meetings with Mr. Jones, Mr. O’Bryant and a review of the TMH Strategic Plan.

The committee voted to extend an offer of a Committee seat to the elected representative of the TMH Family Practice Outreach Physician Groups, currently Wesley Scoles, MD.

 

February 2013

The committee voted unanimously to allow individual committee members to send proxy members from their respective groups to scheduled meetings in their absence. Rob Moss, Executive Director of the Medical Outreach & Physician Services gave a brief historical review of his department and services:

  • Development of the TMH MSO for independent practices using a cafeteria style of options, consultation, payroll, employment of staff, EHR, compliance requirements, etc.
  • Allscripts for most partners with a few exceptions. There would be a hub of shared records among groups functioning like the Big Ben Rhio-TMH Lab, Radiology, Pathology, TMH Cerner.
  • CMS PQRS Parameters for 2013-2015. Groups with EHR will have specialty specific chosen performance measures, Registry based, with Allscripts extracting needed data from the report
  • Groups not on Allscripts will have data gathered by claims based coding. This process will be designed and performed by Rob Moss’s department and the managers of each affected group-Hematology Oncology, Emergency Room, Hospitalists, General Surgeons.
  • Expansion Plans discussed.
  • Recruitments discussed. This was felt to be absolutely critical to the future success of TMHPP. The groups want the highest qualified candidates available. They want much better interaction and response from the TMH departments responsible for recruitment and interviews.
  • There is concern about the limited space for TMHPP Leon County Primary care offices and clinics when discussing expansion and recruitment for especially Family Practice. Recruitment will be limited due to competing private practice groups in town. The facility is badly outdated and deteriorating and remains the major impediment towards successful recruitment and retention of physicians compared to our competitors. The group asked that this be addressed with Mark O’Bryant and his scheduled invitation to the committee in April or May.

read more
Physician Quality Reporting System

The Physician Quality Reporting System (Physician Quality Reporting or PQRS) is a reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals. The program provides an incentive payment to practices with eligible professionals  who satisfactorily report data on quality measures for covered Physician Fee Schedule services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries. Beginning in 2015, the program also applies a payment adjustment to eligible professionals who do not satisfactorily report data on quality measures for covered professional services. The Physician Quality Reporting is mandated by federal legislation. Within the next few months Rob Moss will be visiting practices to ensure that each individual group meets the standards set by the federal government. Below is a link for specific information on how your group practice can get started with PQRS reporting.
 
Reference: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/How_To_Get_Started.html

 

How To Get Started

Step-by-Step Instruction in Getting Started with the Physician Quality Reporting System (PQRS)

STEP 1:

  • Determine if you are eligible to participate for purposes of the PQRS incentive payment and payment adjustment. A list of medical care professionals considered eligible to participate in PQRS is available in the “Downloads” section of this page by clicking on the link titled List of Eligible Professionals. Read this list carefully, as not all entities are considered “eligible professionals because they are reimbursed by Medicare under other fee schedule methods than the Physician Fee Schedule (PFS).

STEP 2:

  • Determine which PQRS reporting method best fits your practice. PQRS has several methods in which measure data can be reported. An eligible professional may chose from the following methods to submit data to CMS: claims-based, registry-based, qualified Electronic Health Record (EHR), or the Group Practice Reporting Option (GPRO).
  • In order to satisfactorily report, it is important to review each method’s specific reporting criteria. For additional guidance, refer to the “2013 Physician Quality Reporting System Participation Decision Tree” in Appendix C of the “2013 Physician Quality Reporting System (PQRS) Implementation Guide”, which is available below as well as in the “Downloads” section on the link titled Measures Code.
  • Reporting via registry or qualified EHR requires eligible professionals to utilize vendors. Registry information, including reporting criteria and vendors, is available in the “Downloads” section of the link titled “Registry Reporting”.
  • EHR reporting information, including reporting criteria and qualified vendors, is available in the “Downloads” section of the link titled Electronic Health Record Reporting.
  • GPRO information may be reviewed under the “Downloads” section of the link titled Group Practice Reporting Option.

STEP 3:

  • If the chosen method to report is claims-based or registry-based, determine which measure reporting option (individual measures or measures group) best fits your practice. Review the specific criteria for the chosen reporting option in order to satisfactorily report.
  • Eligible professionals who choose to report 2013 PQRS individual measures should select at least three clinically applicable measures to submit in an attempt to qualify for a PQRS incentive payment. If fewer than three measures are reported via claims, CMS will apply a measure-applicability validation (MAV) process when determining incentive eligibility. Refer to MAV information available in the “Downloads” section of the link titled “Analysis and Payment”.
  • All PQRS measures and their available reporting methods can be reviewed in the “2013 Physician Quality Reporting System (PQRS) Measures List”, available below as well as in the “Downloads” section of link titled “Measures Codes”.

STEP 4:

Individual Measures or Measures Group

  • Eligible professionals may choose at least three individual measures or one measures group as an option to report on measures to CMS. Review the following supporting documentation for specific criteria to satisfactorily report on these two options.
  • If already participating in PQRS, there is no requirement to select new/different measures for the 2013 PQRS. NOTE: All PQRS measure specifications are annually updated and posted prior to the beginning of each program year; therefore, eligible professionals will need to review them for any revisions or measure retirement for the current program year.
  • Notice that each measure or measure group has a reporting frequency or timeframe requirement for each eligible patient seen during the reporting period by each individual eligible professional (NPI). The reporting frequency (i.e., report each visit, once during the reporting period, each episode, etc.) is found in the instructions section of each measure specification or in the Measure Group Overview section. Ensure that all members of the team understand and capture this information in the patients’ medical record to facilitate reporting.

Individual Measures

  1. 2013 Physician Quality Reporting System (PQRS) Measure Specifications Manual for Individual Claims and Registry Reporting for instructions on how to report claims-based or registry-based individual measures. Just print the pages for the measure specifications you are reporting as the document is very lengthy. The document is available below and in the “Downloads”section of the link titled “Measures Codes”.
  2. 2013 Physician Quality Reporting System (PQRS) Implementation Guide which describes important reporting principles underlying claims-based reporting of measures and includes a sample claim in Form CMS-1500 format. The guide is available below and in the “Downloads” section of the link titled “Measures Codes”.

Measures Groups

  1. 2013 Physician Quality Reporting System (PQRS) Measures Groups Specifications Manual and Release Notes, available below and in the “Downloads” section of the link titled  “Measures Codes”, for claims-based or registry-based reporting of measures groups. Just print the pages for the measure specifications, including the measure group denominator coding, you are reporting. Note that the specifications for a measures group are different from those for individual measures because they identify a common denominator across the measures group. Be sure you use the correct specifications.
  2. Getting Started with 2013 Physician Quality Reporting System (PQRS) Measures Groups is the implementation guide for reporting measures groups. It is available below and in the “Downloads”section of the link titled “Measures Codes”.As you read the specifications and reporting instructions, you will notice that each of the measures has a Quality-Data Code (QDC) (a Current Procedural Terminology [CPT] II code or G-code) associated with it. Note that several measures allow the use of CPT II modifiers: 1P, 2P, 3P, and the 8P reporting modifier. Only allowable CPT II modifiers may be used with a CPT II code. Eligible professionals should use the 8P reporting modifier judiciously for applicable measures they have selected to report. The 8P modifier may not be used indiscriminately in an attempt to meet satisfactory reporting criteria without regard toward meeting the practice’s quality improvement goals.

    To qualify for the incentive, the correct numerator QDC must be reported on at least 80 percent of eligible instances if reporting via a registry or 50 percent of the eligible instances if reporting via claims for each selected measure. A claim is considered “eligible” in PQRS when the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis and/or the CPT Category I service codes on the claim match the applicable diagnosis and encounter codes listed in the denominator criteria of the measure specification.

    Refer to the “2013 Physician Quality Reporting System (PQRS) Quality-Data Code Categories” for a complete list of how each code will be used to calculate performance rates. This document is available below and in the “Download” section of the link titled Measures Codes.

STEP 5:

  • Review information on the PQRS Payment Adjustment. To avoid being subject to a future PQRS payment adjustment, the numerator QDC must be reported at least once during the 12-month reporting period, or the eligible professional must satisfactorily report at least 80 percent of eligible instances if reporting via a registry or 50 percent of the eligible instances if reporting via claims for each selected measure. Refer to the “Payment Adjustment Information” titled link for complete information on how to avoid future PQRS payment adjustments.

 

By: Jeffrey T. Ferraro, MD


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TMH Physician Partners Advisory Committee

Sarmed Ashoo, MD, Emergency Services
Sam.ashoo@tmh.org
431-0755 office
445-0404 cell
 
 
Tim Broeseker, MD, TMH PP, Cancer & Hematology Specialists
Tim.Broeseker@tmh.org
Contact: Sonia Lee, Sonia.Lee@tmh.org
431-5360 office
431-0556 office 2
298-3412 pager
264-2162 cell

Jeffrey Ferraro, MD, Behavioral Health Center
Jeffrey.Ferraro@tmh.org
Contact: Jan Raymond
Jan.Raymond@tmh.org
431-5105 office
551-1004 pager
431-5924 Jan

Michael Forsthoefel, M.D., TMH PP, Internal Medicine & Cardiology with services provided by SMG
MWFor@comcast.net
Contact: Mary Gore, RN, Mary.Gore@tmh.org
216-0141 office

John P. Mahoney, MD, TMH PP, Chief Integration Officer
mahoneysbooks@violinsandbows.com
Contact: Debbie Gwaltney, Debra.Gwaltney@tmh.org
431-5544 office
385-9521 home

Terry Sherraden, MD, TMH PP, Endocrinology Specialists
Tsherraden@pol.net
877-7387 office
386-9715 pager
545-7177 cell

Mark Wheeler, MD, TMH PP, Hospitalists
MWheeler1032@hotmail.com
Contact: Carla Dudley, Carla.Dudley@tmh.org
431-4996 office
551-0897 pager

Donald Zorn, MD, Tallahassee Memorial Family Medicine Residency
Donald.Zorn@tmh.org
Contact: Linda Collier, Linda.Collier@tmh.org
431-3452 office
489-3601 pager
510-7133 cell
510-2700 cell

Richard Zorn, MD, TMH PP, Surgical Specialists
Contact: Janice Benefield, Janice.Benefield@tmh.org
877-5183 ext. 5528 office

Stephanie Derzypolski, TMH Public Relations, Ex-officio
Contact: Jessica Zeigler, Jessica.Zeigler@tmh.org
431-5891 office
228-3799 cell


read more
Update on Electronic Medical Record System

TMH is on the way to having a complete electronic medical record (EMR) system.  We have recently undergone conversion from paper progress notes to electronic notes, aka PowerNotes, throughout the hospital.  Thanks to everyone involved in this transition, from the physicians and other providers who are using the system to the unit secretaries who helped corral the paper.

We continue to build on this knowledge and work on the templates needed to move other documents into the digital domain.  Please don’t hesitate to contact Clinical Informatics with any questions or concerns about this at 431-5585.

We are now enrolling any providers writing orders in the Women’s Pavilion to our Computerized Provider Order Entry (CPOE) classes. These classes start now and continue until go-live on February 26th, 2013.  After this date, all orders in the Women’s Pavilion will be placed directly in the computer and not on paper.  Please call as soon as possible to schedule your training.

In the meantime, many efforts are underway throughout the hospital to improve the utilization of our EMR.  These include our work towards implementing CareAware, which will allow our ICU vital signs to flow directly into the patient record.  Our IT department is also working to increase the memory on the system to support the many new users and uses of the EMR.

Day-to-day support for, and building of the system continues even as we add new projects to the schedule in anticipation of having full CPOE throughout TMH. Thank you for your assistance and patience as we go through this transition.
 

By: Randa Perkins, MD, Hospitalist, Executive Director of Medical Informatics

By: Dean Watson, MD, Chief Medical Officer

read more
Physician Partners Advisory Meeting Highlights

The Tallahassee Memorial Hospital Physician Partners (TMHPP) Advisory Committee was formed this November 2012. The members of this committee represent the TMH Physician Partners. TMHPP is currently composed of over 125 primary and specialty physicians providing health care in over 4 north Florida counties. TMHPP’s composition includes physicians in the Emergency Center, Cancer and Hematology, Behavorial Heath Center, Southern Medical Group, Clinical Genetics, Endocrinology, Hospitalists, Family Practice and Internal Medicine Residency faculty, General Surgery, Rehabilitation, Maternal-Fetal Medicine, Bariatric Center, Pain Center, Palliative Care, Obstetrical Midwifery Services, Marianna Cardiology, Lipid Center and the primary care clinics in Blountstown, Quincy, Wakulla, Monticello, Perry and Southwood.
   

Meeting Minute Highlights for November 2012

The initial goals of the Advisory Committee are to provide direction regarding the performance of its physicians and respective practices employed by or partnered with TMH through TMHPP.

  • Monitor the direction and performance of TMHPP
  • Assist in integration of TMH strategic plan with the Strategic and tactical direction of TMHPP
  • Medical informatics-practice tools and technologies
  • Local and national quality initiatives i.e. HCAHPS, MEANINGFUL USE, PQRI, AMA PCPI, NCQA
  • Regulatory Standards: Joint Commission
  • Recruitment and Marketing

Dr. Mahoney discussed his role as Chief Integration Officer as well as how the committee relates to the medical staff, MEC and the TMH Medical Staff Bylaws. Contact Dr. Mahoney directly at 431-5544 or mahoneysbooks@violinsandbows.com if you need additional information or clarification. Stephanie Derzypolski, Director of Program Development at TMH, joined the committee this February. Rob Moss, Executive Director of the Medical Outreach & Physician Services, has accepted an invitation to join the committee in March.

 

January 2013

1. Cindy Blair, Chief Improvement and Planning Officer met with the committee to outline how her department can assist each TMH Physician Partners office.

The group recommended that Dr. Mahoney, Dr. Ferraro, Ms. Blair and Rob Moss meet to make a recommendation to the Committee on those high volume quality parameters

that will be submitted for calendar year 2013. This recommendation will be e-mailed to Committee members for discussion, vote and approval.

2. The group also voted to have Rob Moss attend the February meeting to discuss updates and implementation schedules regarding Allscripts, EHR, the ability of existing information systems to assist the offices in assuring that mandated quality parameter data will be gathered and reported and an action plan with time lines for groups with expected delays and deficiencies.

3. Dr Mahoney discussed the importance of keeping all TMH-PP members informed and involved in this endeavor. He has requested that Warren Jones’s representative, Stephanie Derzypolski formulate an electronic newsletter that can be sent to all TMH-PP members.

The group requested that Stephanie Derzypolski be invited to join the permanent administrative staff of the TMH-PP Advisory Committee as a non-voting member.

4. The committee addressed areas of immediate review:

  • The primacy of the hospital’s inpatient acute care needs and financial support overwhelming the aspirations of TMH-PP and the future TMH strategic plans for TMH-PP.
  • The committee is in an embryonic stage with no lines of authority, finances, employees, structure or accountability. The TMH Board’s visions, goals, expectations and pathways towards a future successful implementation of TMH-PP are as yet undefined
  • Frustration at attempting to practice out-patient medicine efficiently and having a financially and professionally rewarding practice and a desirable family life. Making sure that TMH does not become merely the enforcer of CMS penalty-driven quality measures, but actually is the driver of a physician-hospital partnership transforming health care for the betterment of our citizens.

5. The Committee discussed current Committee composition.

Discussions about recruitment of other practices and specialty types ensued. Further actions deferred until separate meetings with Mr. Jones, Mr. O’Bryant and a review of the TMH Strategic Plan.

The committee voted to extend an offer of a Committee seat to the elected representative of the TMH Family Practice Outreach Physician Groups, currently Wesley Scoles, MD.

 

February 2013

The committee voted unanimously to allow individual committee members to send proxy members from their respective groups to scheduled meetings in their absence. Rob Moss, Executive Director of the Medical Outreach & Physician Services gave a brief historical review of his department and services:

  • Development of the TMH MSO for independent practices using a cafeteria style of options, consultation, payroll, employment of staff, EHR, compliance requirements, etc.
  • Allscripts for most partners with a few exceptions. There would be a hub of shared records among groups functioning like the Big Ben Rhio-TMH Lab, Radiology, Pathology, TMH Cerner.
  • CMS PQRS Parameters for 2013-2015. Groups with EHR will have specialty specific chosen performance measures, Registry based, with Allscripts extracting needed data from the report
  • Groups not on Allscripts will have data gathered by claims based coding. This process will be designed and performed by Rob Moss’s department and the managers of each affected group-Hematology Oncology, Emergency Room, Hospitalists, General Surgeons.
  • Expansion Plans discussed.
  • Recruitments discussed. This was felt to be absolutely critical to the future success of TMHPP. The groups want the highest qualified candidates available. They want much better interaction and response from the TMH departments responsible for recruitment and interviews.
  • There is concern about the limited space for TMHPP Leon County Primary care offices and clinics when discussing expansion and recruitment for especially Family Practice. Recruitment will be limited due to competing private practice groups in town. The facility is badly outdated and deteriorating and remains the major impediment towards successful recruitment and retention of physicians compared to our competitors. The group asked that this be addressed with Mark O’Bryant and his scheduled invitation to the committee in April or May.

read more
Physician Quality Reporting System

The Physician Quality Reporting System (Physician Quality Reporting or PQRS) is a reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals. The program provides an incentive payment to practices with eligible professionals  who satisfactorily report data on quality measures for covered Physician Fee Schedule services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries. Beginning in 2015, the program also applies a payment adjustment to eligible professionals who do not satisfactorily report data on quality measures for covered professional services. The Physician Quality Reporting is mandated by federal legislation. Within the next few months Rob Moss will be visiting practices to ensure that each individual group meets the standards set by the federal government. Below is a link for specific information on how your group practice can get started with PQRS reporting.
 
Reference: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/How_To_Get_Started.html

 

How To Get Started

Step-by-Step Instruction in Getting Started with the Physician Quality Reporting System (PQRS)

STEP 1:

  • Determine if you are eligible to participate for purposes of the PQRS incentive payment and payment adjustment. A list of medical care professionals considered eligible to participate in PQRS is available in the “Downloads” section of this page by clicking on the link titled List of Eligible Professionals. Read this list carefully, as not all entities are considered “eligible professionals because they are reimbursed by Medicare under other fee schedule methods than the Physician Fee Schedule (PFS).

STEP 2:

  • Determine which PQRS reporting method best fits your practice. PQRS has several methods in which measure data can be reported. An eligible professional may chose from the following methods to submit data to CMS: claims-based, registry-based, qualified Electronic Health Record (EHR), or the Group Practice Reporting Option (GPRO).
  • In order to satisfactorily report, it is important to review each method’s specific reporting criteria. For additional guidance, refer to the “2013 Physician Quality Reporting System Participation Decision Tree” in Appendix C of the “2013 Physician Quality Reporting System (PQRS) Implementation Guide”, which is available below as well as in the “Downloads” section on the link titled Measures Code.
  • Reporting via registry or qualified EHR requires eligible professionals to utilize vendors. Registry information, including reporting criteria and vendors, is available in the “Downloads” section of the link titled “Registry Reporting”.
  • EHR reporting information, including reporting criteria and qualified vendors, is available in the “Downloads” section of the link titled Electronic Health Record Reporting.
  • GPRO information may be reviewed under the “Downloads” section of the link titled Group Practice Reporting Option.

STEP 3:

  • If the chosen method to report is claims-based or registry-based, determine which measure reporting option (individual measures or measures group) best fits your practice. Review the specific criteria for the chosen reporting option in order to satisfactorily report.
  • Eligible professionals who choose to report 2013 PQRS individual measures should select at least three clinically applicable measures to submit in an attempt to qualify for a PQRS incentive payment. If fewer than three measures are reported via claims, CMS will apply a measure-applicability validation (MAV) process when determining incentive eligibility. Refer to MAV information available in the “Downloads” section of the link titled “Analysis and Payment”.
  • All PQRS measures and their available reporting methods can be reviewed in the “2013 Physician Quality Reporting System (PQRS) Measures List”, available below as well as in the “Downloads” section of link titled “Measures Codes”.

STEP 4:

Individual Measures or Measures Group

  • Eligible professionals may choose at least three individual measures or one measures group as an option to report on measures to CMS. Review the following supporting documentation for specific criteria to satisfactorily report on these two options.
  • If already participating in PQRS, there is no requirement to select new/different measures for the 2013 PQRS. NOTE: All PQRS measure specifications are annually updated and posted prior to the beginning of each program year; therefore, eligible professionals will need to review them for any revisions or measure retirement for the current program year.
  • Notice that each measure or measure group has a reporting frequency or timeframe requirement for each eligible patient seen during the reporting period by each individual eligible professional (NPI). The reporting frequency (i.e., report each visit, once during the reporting period, each episode, etc.) is found in the instructions section of each measure specification or in the Measure Group Overview section. Ensure that all members of the team understand and capture this information in the patients’ medical record to facilitate reporting.

Individual Measures

  1. 2013 Physician Quality Reporting System (PQRS) Measure Specifications Manual for Individual Claims and Registry Reporting for instructions on how to report claims-based or registry-based individual measures. Just print the pages for the measure specifications you are reporting as the document is very lengthy. The document is available below and in the “Downloads”section of the link titled “Measures Codes”.
  2. 2013 Physician Quality Reporting System (PQRS) Implementation Guide which describes important reporting principles underlying claims-based reporting of measures and includes a sample claim in Form CMS-1500 format. The guide is available below and in the “Downloads” section of the link titled “Measures Codes”.

Measures Groups

  1. 2013 Physician Quality Reporting System (PQRS) Measures Groups Specifications Manual and Release Notes, available below and in the “Downloads” section of the link titled  “Measures Codes”, for claims-based or registry-based reporting of measures groups. Just print the pages for the measure specifications, including the measure group denominator coding, you are reporting. Note that the specifications for a measures group are different from those for individual measures because they identify a common denominator across the measures group. Be sure you use the correct specifications.
  2. Getting Started with 2013 Physician Quality Reporting System (PQRS) Measures Groups is the implementation guide for reporting measures groups. It is available below and in the “Downloads”section of the link titled “Measures Codes”.As you read the specifications and reporting instructions, you will notice that each of the measures has a Quality-Data Code (QDC) (a Current Procedural Terminology [CPT] II code or G-code) associated with it. Note that several measures allow the use of CPT II modifiers: 1P, 2P, 3P, and the 8P reporting modifier. Only allowable CPT II modifiers may be used with a CPT II code. Eligible professionals should use the 8P reporting modifier judiciously for applicable measures they have selected to report. The 8P modifier may not be used indiscriminately in an attempt to meet satisfactory reporting criteria without regard toward meeting the practice’s quality improvement goals.

    To qualify for the incentive, the correct numerator QDC must be reported on at least 80 percent of eligible instances if reporting via a registry or 50 percent of the eligible instances if reporting via claims for each selected measure. A claim is considered “eligible” in PQRS when the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis and/or the CPT Category I service codes on the claim match the applicable diagnosis and encounter codes listed in the denominator criteria of the measure specification.

    Refer to the “2013 Physician Quality Reporting System (PQRS) Quality-Data Code Categories” for a complete list of how each code will be used to calculate performance rates. This document is available below and in the “Download” section of the link titled Measures Codes.

STEP 5:

  • Review information on the PQRS Payment Adjustment. To avoid being subject to a future PQRS payment adjustment, the numerator QDC must be reported at least once during the 12-month reporting period, or the eligible professional must satisfactorily report at least 80 percent of eligible instances if reporting via a registry or 50 percent of the eligible instances if reporting via claims for each selected measure. Refer to the “Payment Adjustment Information” titled link for complete information on how to avoid future PQRS payment adjustments.

 

By: Jeffrey T. Ferraro, MD


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TMH Physician Partners Advisory Committee

Sarmed Ashoo, MD, Emergency Services
Sam.ashoo@tmh.org
431-0755 office
445-0404 cell
 
 
Tim Broeseker, MD, TMH PP, Cancer & Hematology Specialists
Tim.Broeseker@tmh.org
Contact: Sonia Lee, Sonia.Lee@tmh.org
431-5360 office
431-0556 office 2
298-3412 pager
264-2162 cell

Jeffrey Ferraro, MD, Behavioral Health Center
Jeffrey.Ferraro@tmh.org
Contact: Jan Raymond
Jan.Raymond@tmh.org
431-5105 office
551-1004 pager
431-5924 Jan

Michael Forsthoefel, M.D., TMH PP, Internal Medicine & Cardiology with services provided by SMG
MWFor@comcast.net
Contact: Mary Gore, RN, Mary.Gore@tmh.org
216-0141 office

John P. Mahoney, MD, TMH PP, Chief Integration Officer
mahoneysbooks@violinsandbows.com
Contact: Debbie Gwaltney, Debra.Gwaltney@tmh.org
431-5544 office
385-9521 home

Terry Sherraden, MD, TMH PP, Endocrinology Specialists
Tsherraden@pol.net
877-7387 office
386-9715 pager
545-7177 cell

Mark Wheeler, MD, TMH PP, Hospitalists
MWheeler1032@hotmail.com
Contact: Carla Dudley, Carla.Dudley@tmh.org
431-4996 office
551-0897 pager

Donald Zorn, MD, Tallahassee Memorial Family Medicine Residency
Donald.Zorn@tmh.org
Contact: Linda Collier, Linda.Collier@tmh.org
431-3452 office
489-3601 pager
510-7133 cell
510-2700 cell

Richard Zorn, MD, TMH PP, Surgical Specialists
Contact: Janice Benefield, Janice.Benefield@tmh.org
877-5183 ext. 5528 office

Stephanie Derzypolski, TMH Public Relations, Ex-officio
Contact: Jessica Zeigler, Jessica.Zeigler@tmh.org
431-5891 office
228-3799 cell


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Update on Electronic Medical Record System

TMH is on the way to having a complete electronic medical record (EMR) system.  We have recently undergone conversion from paper progress notes to electronic notes, aka PowerNotes, throughout the hospital.  Thanks to everyone involved in this transition, from the physicians and other providers who are using the system to the unit secretaries who helped corral the paper.

We continue to build on this knowledge and work on the templates needed to move other documents into the digital domain.  Please don’t hesitate to contact Clinical Informatics with any questions or concerns about this at 431-5585.

We are now enrolling any providers writing orders in the Women’s Pavilion to our Computerized Provider Order Entry (CPOE) classes. These classes start now and continue until go-live on February 26th, 2013.  After this date, all orders in the Women’s Pavilion will be placed directly in the computer and not on paper.  Please call as soon as possible to schedule your training.

In the meantime, many efforts are underway throughout the hospital to improve the utilization of our EMR.  These include our work towards implementing CareAware, which will allow our ICU vital signs to flow directly into the patient record.  Our IT department is also working to increase the memory on the system to support the many new users and uses of the EMR.

Day-to-day support for, and building of the system continues even as we add new projects to the schedule in anticipation of having full CPOE throughout TMH. Thank you for your assistance and patience as we go through this transition.
 

By: Randa Perkins, MD, Hospitalist, Executive Director of Medical Informatics

By: Dean Watson, MD, Chief Medical Officer

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Physician Partners Advisory Meeting Highlights

The Tallahassee Memorial Hospital Physician Partners (TMHPP) Advisory Committee was formed this November 2012. The members of this committee represent the TMH Physician Partners. TMHPP is currently composed of over 125 primary and specialty physicians providing health care in over 4 north Florida counties. TMHPP’s composition includes physicians in the Emergency Center, Cancer and Hematology, Behavorial Heath Center, Southern Medical Group, Clinical Genetics, Endocrinology, Hospitalists, Family Practice and Internal Medicine Residency faculty, General Surgery, Rehabilitation, Maternal-Fetal Medicine, Bariatric Center, Pain Center, Palliative Care, Obstetrical Midwifery Services, Marianna Cardiology, Lipid Center and the primary care clinics in Blountstown, Quincy, Wakulla, Monticello, Perry and Southwood.
   

Meeting Minute Highlights for November 2012

The initial goals of the Advisory Committee are to provide direction regarding the performance of its physicians and respective practices employed by or partnered with TMH through TMHPP.

  • Monitor the direction and performance of TMHPP
  • Assist in integration of TMH strategic plan with the Strategic and tactical direction of TMHPP
  • Medical informatics-practice tools and technologies
  • Local and national quality initiatives i.e. HCAHPS, MEANINGFUL USE, PQRI, AMA PCPI, NCQA
  • Regulatory Standards: Joint Commission
  • Recruitment and Marketing

Dr. Mahoney discussed his role as Chief Integration Officer as well as how the committee relates to the medical staff, MEC and the TMH Medical Staff Bylaws. Contact Dr. Mahoney directly at 431-5544 or mahoneysbooks@violinsandbows.com if you need additional information or clarification. Stephanie Derzypolski, Director of Program Development at TMH, joined the committee this February. Rob Moss, Executive Director of the Medical Outreach & Physician Services, has accepted an invitation to join the committee in March.

 

January 2013

1. Cindy Blair, Chief Improvement and Planning Officer met with the committee to outline how her department can assist each TMH Physician Partners office.

The group recommended that Dr. Mahoney, Dr. Ferraro, Ms. Blair and Rob Moss meet to make a recommendation to the Committee on those high volume quality parameters

that will be submitted for calendar year 2013. This recommendation will be e-mailed to Committee members for discussion, vote and approval.

2. The group also voted to have Rob Moss attend the February meeting to discuss updates and implementation schedules regarding Allscripts, EHR, the ability of existing information systems to assist the offices in assuring that mandated quality parameter data will be gathered and reported and an action plan with time lines for groups with expected delays and deficiencies.

3. Dr Mahoney discussed the importance of keeping all TMH-PP members informed and involved in this endeavor. He has requested that Warren Jones’s representative, Stephanie Derzypolski formulate an electronic newsletter that can be sent to all TMH-PP members.

The group requested that Stephanie Derzypolski be invited to join the permanent administrative staff of the TMH-PP Advisory Committee as a non-voting member.

4. The committee addressed areas of immediate review:

  • The primacy of the hospital’s inpatient acute care needs and financial support overwhelming the aspirations of TMH-PP and the future TMH strategic plans for TMH-PP.
  • The committee is in an embryonic stage with no lines of authority, finances, employees, structure or accountability. The TMH Board’s visions, goals, expectations and pathways towards a future successful implementation of TMH-PP are as yet undefined
  • Frustration at attempting to practice out-patient medicine efficiently and having a financially and professionally rewarding practice and a desirable family life. Making sure that TMH does not become merely the enforcer of CMS penalty-driven quality measures, but actually is the driver of a physician-hospital partnership transforming health care for the betterment of our citizens.

5. The Committee discussed current Committee composition.

Discussions about recruitment of other practices and specialty types ensued. Further actions deferred until separate meetings with Mr. Jones, Mr. O’Bryant and a review of the TMH Strategic Plan.

The committee voted to extend an offer of a Committee seat to the elected representative of the TMH Family Practice Outreach Physician Groups, currently Wesley Scoles, MD.

 

February 2013

The committee voted unanimously to allow individual committee members to send proxy members from their respective groups to scheduled meetings in their absence. Rob Moss, Executive Director of the Medical Outreach & Physician Services gave a brief historical review of his department and services:

  • Development of the TMH MSO for independent practices using a cafeteria style of options, consultation, payroll, employment of staff, EHR, compliance requirements, etc.
  • Allscripts for most partners with a few exceptions. There would be a hub of shared records among groups functioning like the Big Ben Rhio-TMH Lab, Radiology, Pathology, TMH Cerner.
  • CMS PQRS Parameters for 2013-2015. Groups with EHR will have specialty specific chosen performance measures, Registry based, with Allscripts extracting needed data from the report
  • Groups not on Allscripts will have data gathered by claims based coding. This process will be designed and performed by Rob Moss’s department and the managers of each affected group-Hematology Oncology, Emergency Room, Hospitalists, General Surgeons.
  • Expansion Plans discussed.
  • Recruitments discussed. This was felt to be absolutely critical to the future success of TMHPP. The groups want the highest qualified candidates available. They want much better interaction and response from the TMH departments responsible for recruitment and interviews.
  • There is concern about the limited space for TMHPP Leon County Primary care offices and clinics when discussing expansion and recruitment for especially Family Practice. Recruitment will be limited due to competing private practice groups in town. The facility is badly outdated and deteriorating and remains the major impediment towards successful recruitment and retention of physicians compared to our competitors. The group asked that this be addressed with Mark O’Bryant and his scheduled invitation to the committee in April or May.

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Physician Quality Reporting System

The Physician Quality Reporting System (Physician Quality Reporting or PQRS) is a reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals. The program provides an incentive payment to practices with eligible professionals  who satisfactorily report data on quality measures for covered Physician Fee Schedule services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries. Beginning in 2015, the program also applies a payment adjustment to eligible professionals who do not satisfactorily report data on quality measures for covered professional services. The Physician Quality Reporting is mandated by federal legislation. Within the next few months Rob Moss will be visiting practices to ensure that each individual group meets the standards set by the federal government. Below is a link for specific information on how your group practice can get started with PQRS reporting.
 
Reference: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/How_To_Get_Started.html

 

How To Get Started

Step-by-Step Instruction in Getting Started with the Physician Quality Reporting System (PQRS)

STEP 1:

  • Determine if you are eligible to participate for purposes of the PQRS incentive payment and payment adjustment. A list of medical care professionals considered eligible to participate in PQRS is available in the “Downloads” section of this page by clicking on the link titled List of Eligible Professionals. Read this list carefully, as not all entities are considered “eligible professionals because they are reimbursed by Medicare under other fee schedule methods than the Physician Fee Schedule (PFS).

STEP 2:

  • Determine which PQRS reporting method best fits your practice. PQRS has several methods in which measure data can be reported. An eligible professional may chose from the following methods to submit data to CMS: claims-based, registry-based, qualified Electronic Health Record (EHR), or the Group Practice Reporting Option (GPRO).
  • In order to satisfactorily report, it is important to review each method’s specific reporting criteria. For additional guidance, refer to the “2013 Physician Quality Reporting System Participation Decision Tree” in Appendix C of the “2013 Physician Quality Reporting System (PQRS) Implementation Guide”, which is available below as well as in the “Downloads” section on the link titled Measures Code.
  • Reporting via registry or qualified EHR requires eligible professionals to utilize vendors. Registry information, including reporting criteria and vendors, is available in the “Downloads” section of the link titled “Registry Reporting”.
  • EHR reporting information, including reporting criteria and qualified vendors, is available in the “Downloads” section of the link titled Electronic Health Record Reporting.
  • GPRO information may be reviewed under the “Downloads” section of the link titled Group Practice Reporting Option.

STEP 3:

  • If the chosen method to report is claims-based or registry-based, determine which measure reporting option (individual measures or measures group) best fits your practice. Review the specific criteria for the chosen reporting option in order to satisfactorily report.
  • Eligible professionals who choose to report 2013 PQRS individual measures should select at least three clinically applicable measures to submit in an attempt to qualify for a PQRS incentive payment. If fewer than three measures are reported via claims, CMS will apply a measure-applicability validation (MAV) process when determining incentive eligibility. Refer to MAV information available in the “Downloads” section of the link titled “Analysis and Payment”.
  • All PQRS measures and their available reporting methods can be reviewed in the “2013 Physician Quality Reporting System (PQRS) Measures List”, available below as well as in the “Downloads” section of link titled “Measures Codes”.

STEP 4:

Individual Measures or Measures Group

  • Eligible professionals may choose at least three individual measures or one measures group as an option to report on measures to CMS. Review the following supporting documentation for specific criteria to satisfactorily report on these two options.
  • If already participating in PQRS, there is no requirement to select new/different measures for the 2013 PQRS. NOTE: All PQRS measure specifications are annually updated and posted prior to the beginning of each program year; therefore, eligible professionals will need to review them for any revisions or measure retirement for the current program year.
  • Notice that each measure or measure group has a reporting frequency or timeframe requirement for each eligible patient seen during the reporting period by each individual eligible professional (NPI). The reporting frequency (i.e., report each visit, once during the reporting period, each episode, etc.) is found in the instructions section of each measure specification or in the Measure Group Overview section. Ensure that all members of the team understand and capture this information in the patients’ medical record to facilitate reporting.

Individual Measures

  1. 2013 Physician Quality Reporting System (PQRS) Measure Specifications Manual for Individual Claims and Registry Reporting for instructions on how to report claims-based or registry-based individual measures. Just print the pages for the measure specifications you are reporting as the document is very lengthy. The document is available below and in the “Downloads”section of the link titled “Measures Codes”.
  2. 2013 Physician Quality Reporting System (PQRS) Implementation Guide which describes important reporting principles underlying claims-based reporting of measures and includes a sample claim in Form CMS-1500 format. The guide is available below and in the “Downloads” section of the link titled “Measures Codes”.

Measures Groups

  1. 2013 Physician Quality Reporting System (PQRS) Measures Groups Specifications Manual and Release Notes, available below and in the “Downloads” section of the link titled  “Measures Codes”, for claims-based or registry-based reporting of measures groups. Just print the pages for the measure specifications, including the measure group denominator coding, you are reporting. Note that the specifications for a measures group are different from those for individual measures because they identify a common denominator across the measures group. Be sure you use the correct specifications.
  2. Getting Started with 2013 Physician Quality Reporting System (PQRS) Measures Groups is the implementation guide for reporting measures groups. It is available below and in the “Downloads”section of the link titled “Measures Codes”.As you read the specifications and reporting instructions, you will notice that each of the measures has a Quality-Data Code (QDC) (a Current Procedural Terminology [CPT] II code or G-code) associated with it. Note that several measures allow the use of CPT II modifiers: 1P, 2P, 3P, and the 8P reporting modifier. Only allowable CPT II modifiers may be used with a CPT II code. Eligible professionals should use the 8P reporting modifier judiciously for applicable measures they have selected to report. The 8P modifier may not be used indiscriminately in an attempt to meet satisfactory reporting criteria without regard toward meeting the practice’s quality improvement goals.

    To qualify for the incentive, the correct numerator QDC must be reported on at least 80 percent of eligible instances if reporting via a registry or 50 percent of the eligible instances if reporting via claims for each selected measure. A claim is considered “eligible” in PQRS when the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis and/or the CPT Category I service codes on the claim match the applicable diagnosis and encounter codes listed in the denominator criteria of the measure specification.

    Refer to the “2013 Physician Quality Reporting System (PQRS) Quality-Data Code Categories” for a complete list of how each code will be used to calculate performance rates. This document is available below and in the “Download” section of the link titled Measures Codes.

STEP 5:

  • Review information on the PQRS Payment Adjustment. To avoid being subject to a future PQRS payment adjustment, the numerator QDC must be reported at least once during the 12-month reporting period, or the eligible professional must satisfactorily report at least 80 percent of eligible instances if reporting via a registry or 50 percent of the eligible instances if reporting via claims for each selected measure. Refer to the “Payment Adjustment Information” titled link for complete information on how to avoid future PQRS payment adjustments.

 

By: Jeffrey T. Ferraro, MD


read more
TMH Physician Partners Advisory Committee

Sarmed Ashoo, MD, Emergency Services
Sam.ashoo@tmh.org
431-0755 office
445-0404 cell
 
 
Tim Broeseker, MD, TMH PP, Cancer & Hematology Specialists
Tim.Broeseker@tmh.org
Contact: Sonia Lee, Sonia.Lee@tmh.org
431-5360 office
431-0556 office 2
298-3412 pager
264-2162 cell

Jeffrey Ferraro, MD, Behavioral Health Center
Jeffrey.Ferraro@tmh.org
Contact: Jan Raymond
Jan.Raymond@tmh.org
431-5105 office
551-1004 pager
431-5924 Jan

Michael Forsthoefel, M.D., TMH PP, Internal Medicine & Cardiology with services provided by SMG
MWFor@comcast.net
Contact: Mary Gore, RN, Mary.Gore@tmh.org
216-0141 office

John P. Mahoney, MD, TMH PP, Chief Integration Officer
mahoneysbooks@violinsandbows.com
Contact: Debbie Gwaltney, Debra.Gwaltney@tmh.org
431-5544 office
385-9521 home

Terry Sherraden, MD, TMH PP, Endocrinology Specialists
Tsherraden@pol.net
877-7387 office
386-9715 pager
545-7177 cell

Mark Wheeler, MD, TMH PP, Hospitalists
MWheeler1032@hotmail.com
Contact: Carla Dudley, Carla.Dudley@tmh.org
431-4996 office
551-0897 pager

Donald Zorn, MD, Tallahassee Memorial Family Medicine Residency
Donald.Zorn@tmh.org
Contact: Linda Collier, Linda.Collier@tmh.org
431-3452 office
489-3601 pager
510-7133 cell
510-2700 cell

Richard Zorn, MD, TMH PP, Surgical Specialists
Contact: Janice Benefield, Janice.Benefield@tmh.org
877-5183 ext. 5528 office

Stephanie Derzypolski, TMH Public Relations, Ex-officio
Contact: Jessica Zeigler, Jessica.Zeigler@tmh.org
431-5891 office
228-3799 cell


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