Applicable to PCPs; and to specialists for the patients for whom they have primary or co- management responsibility regardless of insurance coverage and including Medicare patients.

Seven of the Performance Reporting capabilities identify the population(s) of patients included in the reports (3.1, 3.3, 3.6, 3.10, 3.11, 3.12, and 3.13). The other Performance Reporting capabilities pertain to report attributes (3.2, 3.4, 3.5, 3.7, 3.8, 3.9, 3.14, and 3.15). All capabilities pertaining to report attributes that are marked as in place must be in place for each population of patients marked as included in the reports. 

3.1

Performance reports that allow tracking and comparison of results at a specific point in time across the population of patients are generated for: Diabetes (or, for specialists, relevant patient population)

PCP Guidelines:

1. Performance reports are systematic, routine, aggregate-level reports that provide current,clinically meaningful health care information on the entire population of patients of all ages that are included in the registry (e.g., all diabetics, regardless of pay or and including Medicare patients), allowing comparison across the population of patients, at a single point in time.
2. The performance reports must be actively analyzed and used in self-assessment of provider performance
3. The reports must contain several dimensions of clinical data on patients to enable providers to manage their population of patients. Relevant clinical information that is the focus of attention in established, generally accepted guidelines, and is incorporated in common quality measures pertinent to the chronic illness, must be incorporated in the reports (I.e., physiologic parameters, lab results, medication use, physical findings, and patient behaviors such as peak flow meter use or daily salt intake)
4. It is acceptable for the performance reports to be produced and distributed on a regular basis by the PO or sub-PO, as long as the practice units have the capability to request and receive reports on a timely basis.

Specialist Guidelines:

1. Performance reports are systematic, routine, aggregate-level reports that provide current,clinically meaningful health care information on the population of patients that are included in the relevant registry, allowing comparison of a population of patients at a single point in time
2. The registry may be a population registry, or a clinical registry, such as the ones surgical specialties use to track and address complications
   1. The performance reports must be actively analyzed and used in self-assessment of provider performance
3. The reports must contain several dimensions of clinical data on patients to enable providers to manage their population of patients. Relevant clinical information that is the focus of attention in established, generally accepted guidelines, and is incorporated in common quality measures pertinent to the chronic illness, must be incorporated in the reports (I.e., physiologic parameters, lab results, medication use, physical findings, and patient behaviors such as peak flow meter use or daily salt intake)
4. It is acceptable for the performance reports to be produced and distributed on a regular basis by the PO or sub-PO, as long as the practice units have the capability to request and receive reports on a timely basis.

3.2

Performance reports are generated at the population level, Practice Unit, and individual provider level

PCP Guidelines:

1. Population level optimally consists of PO and/or sub-PO population, but alternatively, as the PO works toward implementing registry capabilities across all practice units, the population level report may be based on a meaningful subset of relevant aggregated practice unit performance
2. Performance reports provide information and allow comparison at the population, practice unit, and individual provider level for all patients currently in the registry, regardless of insurance coverage and including Medicare patients

Specialist Guidelines:

1. Population level optimally consists of PO and/or sub-PO population, but alternatively, as the PO works toward implementing registry capabilities across all practice units, the population level report may be based on a meaningful subset of relevant aggregated practice unit performance
2. Performance reports provide information and allow comparison at the population, practice unit, and individual provider level where feasible (I.e., PO has multiple specialist practices of same type) for all patients currently in the registry, regardless of insurance coverage and including Medicare patients

3.3

Performance reports include patients with at least 2 other conditions PCP and Specialist Guidelines:

1. Reference 2.13
2. Performance reports are being generated for at least 2 other chronic conditions (or for specialists, 2 other conditions relevant to the specialist’s practice) for which there are evidence-based guidelines and the need for ongoing population and patient management,and which are sufficiently prevalent in the practice to warrant inclusion in the registry based on the judgment of the practice leaders (regardless of insurance coverage and including Medicare patients).

3.4

Data contained in performance reports has been fully validated and reconciled to ensure accuracy

PCP and Specialist Guidelines:

1. The practice and PO have process to ensure that data in the registry are representative of the data in the patient’s medical record
   1. For example, where a test result is needed for management, evidence of the test being ordered should not be used as evidence that test was conducted, absent a test result report being received and entered in the record.

3.5

Trend reports are generated, enabling physicians and their Pos/sub-Pos to track, compare and manage performance results for their population of patients over time

PCP Guidelines:

1. Performance reports include both current and past health care information for the population of patients currently in the registry (regardless of insurance coverage and including Medicare patients), allowing analysis and comparison of results across time (e.g.,quarter to quarter, year to year).
2. Trend reports must be generated by the PO/sub-PO at the individual provider, practice unit, and population level
3. Population level optimally consists of PO and/or sub-PO population, but alternatively, as thePO works towards implementing registry capabilities across all practice units, the population level report may be based on a meaningful subset of relevant aggregated practice unit performance

Specialist Guidelines:

1. Performance reports include both current and past health care information for the population of patients currently in the registry (regardless of insurance coverage and including Medicare patients), allowing analysis and comparison of results across time (e.g.,quarter to quarter, year to year).
2. Population level optimally consists of PO and/or sub-PO population where feasible (I.e., PO has multiple specialist practices of same type) but alternatively, as the PO works towards implementing registry capabilities across all practice units, the population level report maybe based on a meaningful subset of relevant aggregated practice unit performance

3.6

Performance reports are generated for the population of patients with: Pediatric Obesity 

PCP and Specialist Guidelines:

1. Reference 3.1.

3.7

Performance reports include all current patients in the practice, including well patients, and include data on preventive services

PCP Guidelines:

1. Performance reports include all current patients in the practice, including well patients, as defined in 2.14 and 3.1
2. Reports include preventive services information

3.8

Performance reports include patient clinical information for a substantial majority of healthcare services received at other sites that are necessary to manage the patient population

PCP and Specialist Guidelines:

1. Reference guidelines for Capability 2.2
2. For all established patients in the registry, the performance reports are expected to include treatment information pertinent to standard quality metrics (e.g., use of beta blockers following AMI), but are not expected to contain comprehensive treatment information as this level of information is often contained in detailed narrative text in clinical notes.
3. Reportable items could include diagnosis and associated labs, physiologic parameters suchas blood pressure, medications, or diagnostic services provided during the encounter.

3.9

Performance reports include information on services provided by specialists or sub-specialists

PCP and Specialist Guidelines:

1. Reference 3.1
2. Information on key preventive or disease specific services provided by specialists or sub-specialistsis incorporated into performance reports.

3.10

Performance reports are generated for the population of patients with: Persistent Asthma 

PCP and Specialist Guidelines:

1. Reference 3.1

3.11

Performance reports are generated for the population of patients with: Coronary Artery Disease [not applicable to pediatric practices]

PCP and Specialist Guidelines:

1. Reference 3.1

3.12

Performance reports are generated for the population of patients with: Congestive Heart Failure [not applicable to pediatric practices]

PCP and Specialist Guidelines:

1. Reference 3.1

3.13

Performance reports are generated for the population of patients with: Pediatric ADD/ADHD 

PCP and Specialist Guidelines:

1.  Reference 3.1

3.14

Performance reports include care management activity PCP and Specialist Guidelines:

1. Care management activity should include the following information for each member of the care management team:
   1. Patient caseload (number of unique patients)
   2. Number of in-person encounters
   3. Number of telephonic encounters

3.15

Key clinical indicators are tracked and reported to external entities to which practices areaccountable for quality measurement

PCP Guidelines:

1. Practices or Pos are tracking and reporting on key clinical indicators, such as rates ofpatients with HTN who are well controlled, and patients with DM who have an A1C showing reasonable control, in a manner consistent with standardized, generally accepted specifications for such measures

Specialist Guidelines:

1. Practices or Pos are tracking and reporting on key clinical indicators relevant to their practices, such as those outlined in HEDIS, PQRS and Meaningful Use standards