To ensure your practice can monitor Patient Adherence, your participation is needed in at least one of the Prescription Drug Monitoring programs (PDMP/PMP) listed below. 

 1. What is the current registration status of your practice with the following PDMPs?

 a. Pharmacy Point of Sale (POS) entity of your state (i.e. 'First Data Bank')  
     Choose one Our practice is currently is registered with a POS entity Not currently registered; our practice plans to register this year Our practice plans to use another PDMD NA - A POS service is not available in our state

 b. Prospective Drug Utilization Review (ProDUR) program of your state
    Choose one Our practice is currently is registered with ProDUR Not currently registered; our practice plans to register this year Our practice plans to use another PDMD NA - Our practice does not service Medicaid beneficiaries NA - ProDUR is not available in our state

 c. Retrospective Drug Utilization Review (RetroDUR) program of your state 
    Choose one Our practice is currently is registered with RetroDUR Not currently registered; our practice plans to register this year Our practice plans to use another PDMD NA - Our practice does not service Medicaid beneficiaries NA - RetroDUR is not available in our state

 d. CMS approved Medication Therapy Management (MTM) program associated with your state
    Choose one Our practice is currently is registered with an MTM Not currently registered; our practice plans to register this year Our practice plans to use another PDMD NA - MTM is not available in our state

 e. Any Behavioral Health Organization (BHO) reporting programs 
     Choose one Our practice is currently is registered with an BHO Not currently registered; our practice plans to register this year Our practice plans to use another PDMD NA - BHO is not available in our state

 f. Please specify the PDMP entity name(s) to which your practice is registered:
   

To ensure CUHSM can complete your QPP submission, please indicate how your current workflow monitors the following conditions:

2. Co-morbid conditions: Diabetes Monitoring for People with Diabetes and Schizophrenia (SMD)

  Choose one Our practice uses electronic C-CDA referral documents from other providers to help monitor this condition Our practice has future plans to use electronic C-CDA documents to monitor this condition No, our practice will not be using electronic C-CDA documents to monitor this condition

3. Co-morbid conditions: Cardiovascular Health Screening for People With Schizophrenia or Bipolar Disorder Who Are Prescribed Antipsychotic Medications

Choose one Our practice uses electronic C-CDA referral documents from other providers to help monitor this condition Our practice has future plans to use electronic C-CDA documents to monitor this condition No, our practice will not be using electronic C-CDA documents to monitor this condition

4. Adherence to Mood Stabilizers for Individuals with Bipolar I Disorder

Choose one Our practice uses electronic C-CDA referral documents from other providers to help monitor this condition Our practice has future plans to use electronic C-CDA documents to monitor this condition No, our practice will not be using electronic C-CDA documents to monitor this condition

5. Care for Older Adults (COA) Medication Review

Choose one Our practice uses electronic C-CDA referral documents from other providers to help monitor this condition Our practice has future plans to use electronic C-CDA documents to monitor this condition No, our practice will not be using electronic C-CDA documents to monitor this condition

In order to comply with Meaningful Use (MU) and plan for future MACRA compliance:
Please indicate which reporting program(s) to which your practice currently is registered:

6. Does your practice currently exchange data with any of the following entities?  
Check all that apply.

   Immunization Registry - Adult
   Immunization Registry - Child
  Syndromic Surveillance
   Electronic Case reporting
   Behavioral Health Organization (BHO)
  Public Health Registry Reporting 
  Prescription Drug Monitoring programs (PDMP/PMP)
  Clinical Data Registry Reporting
  Health Information Exchange (HIE)

Please specify the entity names for your #6 response(s):

To reduce QPP related workflow, please answer the following questions:

7.  Does your EHR have the capacity to generate electronic charts (C-CDA) for your patients?

Choose one Yes, Our EHR can generate a CCDA for each patient No, our EHR is not able to generate a CCDA I don't know what a CCDA is. I will check with my EHR vendor

    Does your EHR have the capacity to receive referral via electronic charts (C-CDA) for your patients?

Choose one Yes, Our EHR has received referral CCDAs for a patient No, our EHR is not able to recieve a CCDA referral document I don't know what a CCDA is. I will check with my EHR vendor

8. In order to identify the optimum patient panel for your QPP report, CUHSM scans codes from 837p electronic documents.  Please check your available methods to provide 837p information:

Superbill from your EHR
Superbill from your PM (Practice Management application software)
Individual 837p documents from your billing company/accounting
Other

9. Please indicate the approximate percent of your patients with the following conditions.

a. % SPMI
b. % PTSD
c. % TBI
d. % Substance Abuse Treatment

e. % COD - Co-Occurring Disorders

Note: The above percentages need not total to 100%.

10. Please describe the payer mix of your patient population:
Use approximate percentages for your estimates.

a. % Medicare
b. % Medicaid
c. % VA - Veterans Administration
d. % Commercial Insurance Carrier
e. % Private Pay / Other

11. To link this to your CUHSM account, please enter the following info: