CQM - record CMS69v10 (MU3)

How to record data in OpenEMR v7

Preliminary OpenEMR configuration

• Externally data load the cqm valueset to use for the coding.
• You may also have to install some CPT codes so please follow the licensing requirements for this and the previously mentioned valueset.
• You also have to make sure that you have a lab service created in the address book and a Procedure->Provider created for the procedure order to work correctly. Finally, make sure that your encounter codes are added to the Encounter Type list.

Create/Find/Edit Person

• For this measure the denominator is looking for aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if most recent BMI was outside of normal parameters.
• Also check for Race and Ethnicity
• Finally set up an insurance company and chose a CQM Source of Payment for that company and add it to the person's chart.

Find/Create encounter

• Use the past encounters or create a new encounter

Encounter Performed

• Under Visit Details select the appropriate dropdown from Type that corresponds to the code in the measure.

Create/Find Care Plan form

• Create a care plan under Clinical->Care Plan

Intervention Order

• Choose Intervention from the Care Plan Type
• Search for the appropriate code from the Procedure Test find code popup
• Select the date
• If this an exception case click the asterix to choose the Negated reason and enter the appropriate code from the look up.
• Save the form

Medication Order

• Choose Planned Medication Act for Type
• Search for the appropriate code from the code popup
• Select the date
• If this an exception case click the asterix to choose the Negated reason and enter the appropriate code from the look up.
• Save the form

Create/Find procedure order

• Create a procedure order under Admin->Procedure Order

Intervention Performed

• Choose Intervention from the Default Procedure Type
• Search for the appropriate code from the Procedure Test find code popup
• Enter the reason for the code for the test by clicking the asterix and use the find code popup to search for the code from the value set and choose pending or completed for the reason status. Otherwise if this an exception case choose negated and enter the appropriate code from the look up.
• Save the order

Create/Find Observation form

• Create an observation form under Clinical->Observation

Physical Exam Performed

• Choose Physical Exam Performed for Type
• Search for the appropriate code from the code popup
• Select the date
• If this an exception case click the asterix to choose the Negated reason and enter the appropriate code from the look up.
• Save the form