eCW Data Entry Instructions for

The purpose of this document is to provide instructions for accurately entering data into eClinicalWorks (eCW) for the clinical quality measures. This guide aims to ensure that healthcare professionals can efficiently and consistently document relevant patient information, thereby supporting the tracking and improvement of clinical quality measures.

2.0 Quality Measures and Definitions

This table includes each measure and the definitions of each measure.

	Measure	Definition
1	Hemoglobin A1c (HbA1c) Test*	Patients aged 18-75 with a diagnosis of diabetes who had at least one HgA1c test within one year prior to the end of the measurement period.
2	Poor Control of HbA1c*	Patients aged 18-75 with a diagnosis of diabetes who did not have at least one HgA1c test within one year prior to the end of the measurement period or who’s last HgA1c test was > 9%.
3	Control of Hba1c*	Patients aged 18-75 with a diagnosis of diabetes who had at least one HgA1c test within one year prior to the end of the measurement period and who’s last HgA1c test was < 8%.
4	Retinal Eye Exams	Patients aged 18-75 with a diagnosis of diabetes who received a retinal eye exam from an ophthalmologist or optometrist within one year prior to the end of the measurement period.
5	Foot Exams	Patients aged 18-75 with a diagnosis of diabetes who received at least one LEAP or diabetic/sensory foot exam within one year prior to the end of the measurement period.
6	Diabetes Blood Pressure Control	Patients aged 18-75 with a diagnosis of diabetes whose blood pressure at their last encounter was equal to or <140/90.
7	Hypertensive Blood Pressure Measurement	Patients aged 18-85 with a diagnosis of hypertension who had a blood pressure measurement taken at their last encounter
8	Hypertensive Blood Pressure Control*	Hypertensive Adults 18–59 years of age whose blood pressure was <140/90 mm Hg, hypertensive Adults 60–85 years of age, with a diagnosis of diabetes, whose blood pressure was <140/90 mm Hg, and hypertensive Adults 60–85 years of age, without a diagnosis of diabetes, whose blood pressure was <150/90 mm Hg.
9	Breast Cancer Screening 40+ years	Women aged 40-74 who received a mammogram within two years prior to the end of the reporting period.
10	Breast Cancer Screening 50+ years*	Women aged 50-74 who received a mammogram within two years prior to the end of the reporting period.
11	Cervical Cancer Screening*	Women aged 21-64 with cervical cytology performed within the last 3 years, Women aged 30-64 who had cervical high risk hrHPV testing performed within the last 3 years, and Women 30-64 years of age who had cervical cytology/high risk hrHPV cotesting within the last 5 years
12	Colorectal Cancer Screening*	Patients aged 45-75 with a diagnosis of diabetes who received a Colonoscopy within 10 years, Flexible sigmoidoscopy within 5 years, or Fecal occult blood or FIT test within 12 months of the end of the measurement period.
13	Pneumococcal Vaccination	Patients aged 65 or older who have had a pneumococcal vaccination at any point prior to their most recent encounter.
14	Primary Care Visit Depression Screening*	Patients who completed primary care visits with a documented PHQ-2 or PHQ-9.
15	Active Patient Depression Screening	Patients who completed 2 primary or specialty care visits with at least one documented PHQ-2 or PHQ-9 in the 15 months prior to the end of the measurement period.
16	Behavioral Health Follow Up After Positive Depression Screen	Patients who completed a primary care visits within 3 months with a positive PHQ Screen and received any BH visits within 2 months of the positive PHQ screen. *A positive PHQ2 score is considered a score of 2 or 3 for an individual response, and/or 2-6 for the sum of both PHQ2 questions. A positive PHQ9 score is considered a score of 10 or up.
17	Depression Symptom Reduction	Patients who had a BH evaluation (CPT code 90791 or 90792) within 6 months and have at least one additional PHQ9 where the most recent PHQ9 score is either ≤9 OR a decrease of ≥50% from the baseline score

*Shared publicly

3.0 Instructions for Entering Measures in eCW

3.1 [VV4] [VV5] Entering Hemoglobin A1c Test, Poor HbA1c Control, and Control of HbA1c

This section describes how to enter A1c lab tests and results for patients.

Instructions:

In the Progress Note > Treatment section > Labs > confirm a diagnosis has been added and selected on the left-hand side.
Type in A1C in Search Order field. After the Test is selected it will populate on the right-hand side of Today’s Orders.

Entering the result:

Go into the Patient Hub, select Labs, and then click on the Lab.
Click on Received box.
Enter the Date the results were ordered, collected, performed, (Order & Collection tab) and received (Results tab)
Enter the Result and any other clinical information.

To close the procedure permanently, click Reviewed at the top.

3.2 Retinal Eye Exams

This section describes how to enter an eye exam performed by an ophthalmologist or optometrist or referral results for patients.

Instructions:

To enter exam results in Progress Note, go to Examination>Ophthalmology Referral.
In the DIABETES EYE EXAM row and click under Observation to enter the date and result.

3.3 Foot Exam

This section describes how to capture foot exams for patients with Diabetes.

Instructions:

In the Progress Note, go to Examination>General Examination.
Scroll to the FOOT EXAM row and click under Observation to enter the date and result.

3.4 Entering Data for Diabetes Blood Pressure Control, Hypertensive Blood Pressure, and Hypertensive Blood Pressure Control

This section describes how to enter blood pressure for patients.

Instructions:

In the Progress Note > Vitals > check box Pop up then type in the field BP(mm Hg) this pop up will appear then enter the data.

3.5 Breast Cancer Screening

This section describes how to enter mammograms and mammogram referrals for patients.

Ordering the test:

Click on Treatment in the Progress Note, then click Browse next to Diagnostic Imaging (DI).
Be sure a diagnosis code is added.
Search for the DI under the correct Lab Company.
1. When placing an order, providers should select the DI Company “Community Radiology” or “DigitalOne report” for Shady Grove Radiology.
  - Use the prefix “MG” to search for mammograms at Shady Grove Radiology.
  - Use the prefix “MA” to search for mammograms at Community Radiology.
Select the test and click OK to close the window.

Mammogram Referral:

To send a mammogram referral and assign it to the coordinator (instead of ordering it through Treatment), click on the Referral icon in the upper right hand corner from the Treatment screen:

Once the results come back, be sure to attach any documents and close out the referral (check Addressed Status)

To find the Open Referral for the patient, go to the Patient Hub>Referrals.

Entering the result:

Go to the Patient Hub and select DI.
Attach the scanned report (optional for paperless clinics) and click on Received.
Enter the Date the results were ordered, collected , performed, (Order & Collection tab) and received (Results tab)
Enter the Result and any other clinical information.
For a mammogram you must put in the bi-rad value.
To close the DI permanently, click Reviewed at the top.

Mammogram (Self-Reported) under Diagnostic Imaging:

Click Received, select a value in Result and fill out the information in structured fields – Date Completed (mm/dd/yyyy), Location and Result (Bi-Rad) – and attach the scanned report.
1. If the patient does not present a report, you can enter the month/year value (mm/yyyy) as reported by the patient in the column titled Date Completed and skip the scanned document attachment step. However, in this case the results will NOT satisfy CDSS, Quality Measures and other alerts in the system.

Mammogram (declined by patient) under Diagnostic Imaging:

If the patient declines a mammogram, you can document this in Treatment>DI>Search “Mammogram (declined by patient).

Alternatively, you can enter a decline under Examination>General Examination>Breast Examination>Most Recent Mammogram. Details can be entered in the Observation columns.

Measure Exclusion - Documenting a Bilateral Mastectomy (exclusion from quality measure denominator):

When searching for an assessment code to document a bilateral mastectomy, enter the HEDIS Exclusion code Z90.13 (Acquired absence of bilateral breasts and nipples) in the Assessment section of the Progress Note.

3.7 Cervical Cancer Screening

This section describes how to enter cervical cancer screening and colorectal cancer screening and results including PAP, FOBT, and FIT lab tests for patients.

Ordering the test:

Click on Treatment in the Progress Note, then click Browse next to Labs.
Be sure a diagnosis code is added.
Search for the lab.
Select the test and click OK for the test to close and appear in the Progress Note.

Entering the result:

Go into the Patient Hub, select Labs, and then click on the Lab.
Click on Received box.
Enter the Date the results were ordered, collected, performed, (Order & Collection tab) and received (Results tab)
Enter the Result and any other clinical information.
To close the procedure permanently, click Reviewed at the top.

PAP Smear (Self-Reported) under Labs:

Search for and select PAP Smear (self-reported) in the Labs search field.

Close the Treatment window and click on Labs at the top of the Progress Note.

Open the PAP Smear (self-reported) lab you just ordered.
Click Received, select a value in Result and fill out the information in structured fields – Date Completed (mm/dd/yyyy), Location and Result – and attach the scanned report (if available).
1. If the patient does not present a report, you can enter the year value (yyyy) or month/year value (mm/yyyy) as reported by the patient in the column titled Date Completed and skip the scanned document attachment step, but in this case the results will NOT satisfy CDSS, Quality Measures and other alerts in the system.

PAP Smear (declined by patient) under Labs:

Search for and select PAP Smear (declined by patient) in the Labs search field.

Measure Exclusion – PAP Smear – Documenting Absence of Cervix (exclusion from quality measure denominator):

When searching for an assessment code to document the absence of a cervix in the Progress Note, choose from the HEDIS Exclusions codes list below to enter in the Assessment section –

Table 2: Cervical Cancer Screening ICD Exclusion Codes

Value Set Name[VV6]	ICD Code	Definition[VV7]
Absence of Cervix	Q51.5	[Q51.5] Agenesis and aplasia of cervix
Absence of Cervix	Z90.710	[Z90.710] Acquired absence of both cervix and uterus
Absence of Cervix	Z90.712	[Z90.712] Acquired absence of cervix with remaining uterus
Absence of Cervix	0UTC0ZZ	[0UTC0ZZ] Resection of Cervix, Open Approach
Absence of Cervix	0UTC4ZZ	[0UTC4ZZ] Resection of Cervix, Percutaneous Endoscopic Approach
Absence of Cervix	0UTC7ZZ	[0UTC7ZZ] Resection of Cervix, Via Natural or Artificial Opening
Absence of Cervix	0UTC8ZZ	[0UTC8ZZ] Resection of Cervix, Via Natural or Artificial Opening Endoscopic

3.6 Colorectal Cancer Screening

This section describes how to enter colorectal cancer screening and results including colonoscopy, double contrast barium, or flexible sigmoidoscopy for patients.

Ordering the test:

Click on Treatment in the Progress Note, then click Browse next to Procedure.
Be sure a diagnosis code is added.
Search for the Procedure.
Select the test and click OK for the test to close and appear in the Progress Note.

Colonoscopy Referral:

To send a Colonoscopy referral and assign it to the coordinator (instead of ordering it through Treatment), click on the Referral icon in the upper right hand corner from the Treatment screen:

Once the results come back, be sure to attach any documents and close out the referral (check Addressed Status) To find the Open Referral for the patient, go to the Patient Hub>Referrals.

Entering the result:

Go into the Patient Hub, select Procedures, and then click on the Procedure.
Click on Received box.
Enter the Date the results were ordered, collected, performed, (Order & Collection tab) and received (Results tab)
Enter the Result and any other clinical information.
To close the procedure permanently, click Reviewed at the top.

Colon Cancer Screening (Self-Reported) under Procedures in Treatment:

Search for and select Colon cancer screening (self-reported) in the Procedures search field.

Close the Treatment window and click on Procedures at the top of the Progress Note.

Open the Colon cancer screening (self-reported) procedure you just ordered.
Click Received, select a value in Result and fill out the information in structured fields – Date Completed (mm/dd/yyyy), Location and Result – and attach the scanned report (if available).
1. If the patient does not present a report, you can enter the year value (yyyy) or month/year value (mm/yyyy) as reported by the patient in the column titled Date Completed and skip the scanned document attachment step, but in this case the results will NOT satisfy CDSS, Quality Measures and other alerts in the system.

Colon Cancer Screening (declined by patient) under Procedures:

Search for and select Colon cancer screening (declined by patient) in the Procedures search field.

Measure Exclusion - Colorectal Cancer or Total Colectomy (exclusion from quality measure denominator):

When searching for an assessment code, choose from the HEDIS Exclusions codes list to enter into the Assessment section of the Progress Note.

Table 1: Colorectal Cancer Screening ICD Exclusion Codes

Value Set Name	Code	Definition[VV8]
Colorectal Cancer	C18.0	[C18.0] Malignant neoplasm of cecum
Colorectal Cancer	C18.1	[C18.1] Malignant neoplasm of appendix
Colorectal Cancer	C18.2	[C18.2] Malignant neoplasm of ascending colon
Colorectal Cancer	C18.3	[C18.3] Malignant neoplasm of hepatic flexure
Colorectal Cancer	C18.4	[C18.4] Malignant neoplasm of transverse colon
Colorectal Cancer	C18.5	[C18.5] Malignant neoplasm of splenic flexure
Colorectal Cancer	C18.6	[C18.6] Malignant neoplasm of descending colon
Colorectal Cancer	C18.7	[C18.7] Malignant neoplasm of sigmoid colon
Colorectal Cancer	C18.8	[C18.8] Malignant neoplasm of overlapping sites of colon
Colorectal Cancer	C18.9	[C18.9] Malignant neoplasm of colon, unspecified
Colorectal Cancer	C19	[C19] Malignant neoplasm of rectosigmoid junction
Colorectal Cancer	C20	[C20] Malignant neoplasm of rectum
Colorectal Cancer	C21.2	[C21.2] Malignant neoplasm of cloacogenic zone
Colorectal Cancer	C21.8	[C21.8] Malignant neoplasm of overlapping sites of rectum, anus and anal canal
Colorectal Cancer	C78.5	[C78.5] Secondary malignant neoplasm of large intestine and rectum
Colorectal Cancer	Z85.038	[Z85.038] Personal history of other malignant neoplasm of large intestine
Colorectal Cancer	Z85.048	[Z85.048] Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus
Total Colectomy	0DTE0ZZ	[0DTE0ZZ] Resection of Large Intestine, Open Approach
Total Colectomy	0DTE4ZZ	[0DTE4ZZ] Resection of Large Intestine, Percutaneous Endoscopic Approach
Total Colectomy	0DTE7ZZ	[0DTE7ZZ] Resection of Large Intestine, Via Natural or Artificial Opening
Total Colectomy	0DTE8ZZ	[0DTE8ZZ] Resection of Large Intestine, Via Natural or Artificial Opening Endoscopic

3.8 Pneumococcal Vaccination

This section describes how to enter immunizations for patients.

Instructions:

In the Progress Note, open Immunizations or Therapeutic Injections.
Select Immunization Schedule tab, (or Flu Schedule).
Select desired entry and click Add.

Fill in form with all relevant Information such as Date, Dosage, Lot Number, Manufacturer, VIS, VFC,
Enter when, where, and how injection is given, by whom.
Change Status to Administered and click OK or Save and new to document another.

3.9 Entering Data for Primary Care Visit Depression Screening, Active Patient Depression Screening, Follow Up After Positive Depression Screen, and Depression Symptom Reduction

This section describes how to enter depression screening results including PHQ-2 and PHQ-9 for patients.

PHQ-2

Within the Progress Notes select SF (smartforms)

The digital form will appear, you will then enter the information requested. Then click Save.

PHQ-9

Within the Progress Notes select SF(smartforms)

The digital form will appear, you will then enter the information requested. Then click Save

4.0 Other (non-Montgomery Cares)

This section describes how to enter exams, classes, and counseling for patients that are related to but not included in the quality measures.

Clinical Breast Exam

In the Progress Note, go to Examination>General Examination.
Scroll to the “BREASTS” row and click under Observation to enter the date and result.

Diabetes Education Classes

Enter a code for the type of diabetic class within the Progress Note:

Go to Billing > Procedure Codes > Add CPT.
Type S9465 (HCPCS code) next to CPT or Diabetic Mgmt next to description (see screenshot below)
Click on the entry to add it to the list.

Counseling for Patients:

Can be entered in the Preventive Medicine section of Progress notes.

Select Counseling> Communication to patient.
Click in the Values field to enter dates.
Click in Notes field to enter structured data.

[VV1]@Jamika Farlow Hi Jamika, please add your name ant title here

[VV2]@Sophy Yang @Jamika Farlow

For the Table of Contents, recommend simplifying it

1.0 Purpose

2.0 Quality Measures and Definitions

3.0 Instructions for Entering Each Measure

3.1 Hemoglobin A1c Test

3.2 Poor HbA1c Control

3.3 Control of HbA1c

The titles should be the same as the titles in the table in Section 2.0.

It makes the connection clear between the instructions and each measure.

Also for the mammogram section, in the TOC, I would only show the first two levels (7.0 and 7.1, the remaining sections below (ordering the test, entering the result) are too detailed for a Table of Contents.). It will also help the TOC fit on one page.

[VV3]@Sophy Yang always start this on a new page

[VV4]@Sophy Yang @Jamika Farlow I adjusted this one for you as an example.

[VV5]You’ll need to update the label with whatever you have in the table

What does this table mean, why is it here? Always include a bit of an explanation about why any table is being included. [VV6]

color @Sophy Yang [VV7]

Update with branding color [VV8]

Primary Care Coalition

MCares eCW Data Entry for Clinical Quality Measures (08052024) Print

eCW Data Entry Instructions for

MCares Clinical Quality Measures

1[VV3] .0 Purpose

2.0 Quality Measures and Definitions

3.0 Instructions for Entering Measures in eCW

3.1 [VV4] [VV5] Entering Hemoglobin A1c Test, Poor HbA1c Control, and Control of HbA1c

Entering the result:

3.2 Retinal Eye Exams

3.3 Foot Exam

3.4 Entering Data for Diabetes Blood Pressure Control, Hypertensive Blood Pressure, and Hypertensive Blood Pressure Control

3.5 Breast Cancer Screening

Ordering the test:

Mammogram Referral:

Entering the result:

Mammogram (Self-Reported) under Diagnostic Imaging:

Mammogram (declined by patient) under Diagnostic Imaging:

Measure Exclusion - Documenting a Bilateral Mastectomy (exclusion from quality measure denominator):

3.7 Cervical Cancer Screening

Ordering the test:

Entering the result:

PAP Smear (Self-Reported) under Labs:

PAP Smear (declined by patient) under Labs:

Measure Exclusion – PAP Smear – Documenting Absence of Cervix (exclusion from quality measure denominator):

3.6 Colorectal Cancer Screening

Ordering the test:

Colonoscopy Referral:

Entering the result:

Colon Cancer Screening (Self-Reported) under Procedures in Treatment:

Colon Cancer Screening (declined by patient) under Procedures:

Measure Exclusion - Colorectal Cancer or Total Colectomy (exclusion from quality measure denominator):

3.8 Pneumococcal Vaccination

3.9 Entering Data for Primary Care Visit Depression Screening, Active Patient Depression Screening, Follow Up After Positive Depression Screen, and Depression Symptom Reduction

PHQ-2

PHQ-9

4.0 Other (non-Montgomery Cares)

Clinical Breast Exam

Diabetes Education Classes

Counseling for Patients:

MCares eCW Data Entry for Clinical Quality Measures (08052024) Print

eCW Data Entry Instructions for

MCares Clinical Quality Measures

1[VV3] .0 Purpose

2.0 Quality Measures and Definitions

3.0 Instructions for Entering Measures in eCW

3.1 [VV4] [VV5] Entering Hemoglobin A1c Test, Poor HbA1c Control, and Control of HbA1c

Entering the result:

3.2 Retinal Eye Exams

3.3 Foot Exam

3.4 Entering Data for Diabetes Blood Pressure Control, Hypertensive Blood Pressure, and Hypertensive Blood Pressure Control

3.5 Breast Cancer Screening

Ordering the test:

Mammogram Referral:

Entering the result:

Mammogram (Self-Reported) under Diagnostic Imaging:

Mammogram (declined by patient) under Diagnostic Imaging:

Measure Exclusion - Documenting a Bilateral Mastectomy (exclusion from quality measure denominator):

3.7 Cervical Cancer Screening

Ordering the test:

Entering the result:

PAP Smear (Self-Reported) under Labs:

PAP Smear (declined by patient) under Labs:

Measure Exclusion – PAP Smear – Documenting Absence of Cervix (exclusion from quality measure denominator):

3.6 Colorectal Cancer Screening

Ordering the test:

Colonoscopy Referral:

Entering the result:

Colon Cancer Screening (Self-Reported) under Procedures in Treatment:

Colon Cancer Screening (declined by patient) under Procedures:

Measure Exclusion - Colorectal Cancer or Total Colectomy (exclusion from quality measure denominator):

3.8 Pneumococcal Vaccination

3.9 Entering Data for Primary Care Visit Depression Screening, Active Patient Depression Screening, Follow Up After Positive Depression Screen, and Depression Symptom Reduction

PHQ-2

PHQ-9

4.0 Other (non-Montgomery Cares)

Clinical Breast Exam

Diabetes Education Classes

Counseling for Patients:

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