Report Results - Tabulated Chart Abstraction Data

Review the tabulated results from the first data abstraction. After reviewing the chart data below, select the quality measure(s) you would like to focus on during the improvement phase by checking the box to the left of each quality measure. You must select at least one quality measure and approve the report by clicking the submit button at the bottom of the page.

After analyzing the report data, select quality measure(s) for the improvement phase that you performed less than expected on or that will have a meaningful impact on your practice.

	Examine Systems: Practice Characteristics
	Type of practice: Hospital
	You provide mainly: Consultative Care
	Patient Chart Format: Both paper and EMR

Select	Demographics	n	%	avg
	Male	6	24
	Female	19	76
	Age Distribution
	under 30	0	0
	30 - 44	2	8
	45 - 59	7	28
	60 and over	16	64
	Race
	African American/Black	9	36
	American Indian/Alaskan Native	5	20
	Native Hawaiian/Pacific Islander	3	12
	Asian	2	8
	Caucasian/White	12	48
	Other Race	2	8
	No Race Specified	0	0
	Ethnicity
	Hispanic/Latino	10	40
	Not Hispanic/Latino	15	60
	Patient Care
	Sole usual source of care for patient's rheumatoid arthritis	20	80
	Tabulated Chart Abstraction Data
	Confirmed diagnosis of rheumatoid arthritis	25	100
	Initial Measures within three months of diagnosis ^QI
	Joint exam	23	92
	Functional status assessment	23	92
	Acute phase reactant	23	92
	Measurement of pain	23	92
	Physician global assessment	23	92
	Patient global assessment	23	92
	Measures Performed within Last 12 Months ^QI
	Joint exam	23	92	3.40
	Functional status assessment	23	92	3.36
	Acute phase reactant	23	92	3.16
	Measurement of pain	23	92	3.36
	Physician global assessment	23	92	3.36
	Patient global assessment	23	92	3.36

	Treatment^QI
	Patient is being treated with a DMARD	20	80
	Patient is NOT being treated with a DMARD	5	20
	Contrandication	1	4
	Patient refused	0	0
	Inactive disease	2	8
	Reason not documented	1	4
	Other reason specified	1	4
	Course of Action ^QI
	Patient is being treated with a DMARD and there is evidence of increased disease activity or there is evidence of progression of RA bony damage over a 6-month period of time	0	0
	Drug Safety
	Informing patients about risks^QI
	Number of patients newly prescribed a DMARD	3	12
	For patients newly prescribed a DMARD, a documented discussion was held with the patient about the risks of the chosen therapy	3	100
	Number of patients newly prescribed a NSAID	0	0
	Number of patients newly prescribed a glucocorticoid	3	12
	For patients newly prescribed a glucocorticoid, a documented discussion was held with the patient about the risks of the chosen therapy	2	67
	Number of patients newly prescribed a narcotic	2	8
	For patients newly prescribed a narcotic, a documented discussion was held with the patient about the risks of the chosen therapy	1	50

	Prophylaxis for patients at risk for gastrointestinal bleeding^QI
	Number of patients treated with 1) a non-selective NSAID or 2) a COX-2 selective NSAID plus aspirin	8	32
	Number of patients treated with 1) a non-selective NSAID or 2) a COX-2 selective NSAID plus aspirin with risk factors	4	50
	Number of patients treated with 1) a non-selective NSAID or 2) a COX-2 selective NSAID plus aspirin with risk factors for upper gastrointestinal bleeding treated concomitantly with either misoprostol or a proton pump inhibitor	3	75

	Lab monitoring - gastrointestinal bleeding ^QI
	Number of patients treated with a non-selective NSAID	8	32
	Number of patients treated with a daily NSAID (selective or non-selective) with risk factors for upper gastrointestinal bleeding	4	50
	Number of patients treated with a daily NSAID (selective or non-selective) with risk factors for upper gastrointestinal bleeding with hemoglobin or hematocrit performed at baseline and during the first year after initiating therapy.	4	100

	Lab monitoring - renal insufficiency ^QI
	Number of patients treated with daily NSAIDs (selective or non-selective)	8	32
	Number of patients treated with daily NSAIDs with risk factor for developing renal insufficiency	3	38
	Number of patients treated with daily NSAIDs with risk factor for developing renal insufficiency with a serum creatinine assessed at baseline, within the first 3 months	3	100
	Number of patients treated with daily NSAIDs with risk factor for developing renal insufficiency with a serum creatinine performed in the last 12 months	3	100

Laboratory monitoring for newly prescribed DMARDs ^QI
Number of patients treated with Sulfasalazine		0	0
Number of patients treated with Methotrexate		6	50
	with Complete Blood Count	6	100	0
	with Serum Creatinine	6	100	0
	with AST or ALT	6	100	0
	with Albumin	6	100	0
	with Alkaline Phosphatase	6	100	0
	with CXR	2	33.33	0
Number of patients treated with Leflunomide		0	0
Number of patients treated with Etanercept		2	16.67
	with CXR	0	0
	with PPD	0	0
Number of patients treated with Anakinra		2	16.67
	with CXR	0	0
	with PPD	0	0
Number of patients treated with Infliximab		2	16.67
	with CXR	1	50	0
	with PPD	0	0
Number of patients treated with Adalimumab		0	0
Number of patients treated with Azathioprine		0	0
Number of patients treated with D-Penicillamine		1	8.33
	with Complete Blood Count	0	0
	with Serum Creatinine	0	0
	with Urinary protein	0	0
Number of patients treated with Gold		0	0
Number of patients treated with Cyclosporine		0	0
Number of patients treated with Cyclophosphamide		0	0
Number of patients treated with Oral Glucocorticoids		0
Laboratory monitoring for established DMARDs ^QI
Number of patients treated with Hydroxychloroquine		1	8.33
	with Fundoscopic exam	0	0
Number of patients treated with Sulfasalazine		0	0
Number of patients treated with Methotrexate		6	50
	with Complete Blood Count	6	100	5.83
	with Serum Creatinine	6	100	5.83
	with AST or ALT	6	100	5.83
	with Albumin	6	100	5.83
Number of patients treated with Leflunomide		0	0
Number of patients treated with Azathioprine		0	0
Number of patients treated with D-Penicillamine		1	8.33
	with Complete Blood Count	0	0
	with Urinary protein	0	0
Number of patients treated with Gold		0	0
Number of patients treated with Cyclosporine		0	0
Number of patients treated with Cyclophosphamide		0	0
Number of patients treated with Oral Glucocorticoids		0	0

	Examine Systems ? Improvement Process Summary Below is a summary of what you reported in the Examine Systems ? Improvement Process.
	Working well in the practice:
	The practice reduces the risk of delay in receiving care by performing triage of new patients requesting an appointment.
	The practice system for scheduling appointments tracks patients who cannot be accommodated within their desired timeframe and calls them back with openings.
	The practice reduces the risk of diagnostic errors by communicating results of testing to patients in a timely manner, with instructions on what to do next.
	The practice incorporates the improvement process into its work by developing, implementing, and studying the impact of improvement ideas.The practice incorporates the improvement process into its work by developing, implementing, and studying the impact of improvement ideas.
	The practice reduces the risk of delay in receiving care by instructing patients on when to call 911 or go to an emergency room rather than contact the practice.
	The practice reduces the risk of diagnostic errors by communicating results of testing to patients in a timely manner, with instructions on what to do next.
	The practice reduces the risk of diagnostic errors by communicating results of testing to patients in a timely manner, with instructions on what to do next.
	The practice incorporates the improvement process into its work by surveying patients about the care they receive.








	Could use improvement:
	The practice system for scheduling appointments tracks patients who cannot be accommodated within their desired timeframe and calls them back with openings.
	The practice reduces the risk of delay in receiving care by performing triage of new patients requesting an appointment.
	The practice incorporates the improvement process into its work by surveying patients about the care they receive.



	Not available or operational in the practice:
	The practice reduces the risk of delay in receiving care by instructing patients on when to call 911 or go to an emergency room rather than contact the practice.
	The practice incorporates the improvement process into its work by developing, implementing, and studying the impact of improvement ideas.The practice incorporates the improvement process into its work by developing, implementing, and studying the impact of improvement ideas.