Improvement Activities is one of the four MIPS performance categories. EHRs were not certified for Improvement Activities; therefore, proof of compliance is the practice's responsibility. Practices must have policies and procedures that they maintain throughout the reporting period. To prove that they've done an activity, we recommend taking a screen capture within our application or third-party application.
To assist, NextGen® Office recommends the activities (listed in the table below), which are the activities our team knows the majority of our providers can achieve.
Reminder: Enroll in Quality measures in Administration: EHR Reporting and Quality Measures or within the MIPS Dashboard (Quality dashboard).
Note: You must create a new enrollment in Administration: EHR Reporting and Quality Measures if you want to see the updated measures for Improvement Activities.
Requirements
Quality Payment Program Improvement Activities Requirements
Workflow
- NextGen Office provides guidance for recommended activities based on our provider population and EHR features.
- Eligible clinicians can attest to any activity that they believe was performed and provable during the reporting period.
- For all selected activities, we recommend uploading policy and procedures outlining how your practice has complied with the activity requirements.
- We created document types for community resources to help meet a number of recommended activities.
- Community resources appear in the Patient Portal FOR ALL PATIENTS after they are uploaded in Improvement Activities under the Community Resources section.
- Note: The document will only appear in Community Resources for all patients if the document is not linked to a patient chart.
- For the measure description, select the measure name.
- To learn how to manage and upload documents, refer to Improvement Activities Document Management.
Recommended Activities
Refer to the Quality Payment Program website for the latest Improvement Activities.
| Activity | Why Is This Activity Recommended? | Weight |
|---|
| Consulting AUC Using Clinical Decision Support When Ordering Advanced Diagnostic Imaging | NextGen Office EHR is integrated with National Decision Support Company's solution (CareSelect) at the time of ordering advanced imaging to assist you to incorporate the AUC Program requirement into the radiology ordering workflow. For information on the AUC Program, refer to our Appropriate Use Criteria Program FAQ or CMS's Appropriate Use Criteria Program webpage. For instructions on how to use the AUC feature when ordering a radiology test, refer to the Consult AUC section in Radiology Orders. | High |
| Care Coordination Agreements That Promote Improvements in Patient Tracking across Settings | This activity relates to the documentation of policy and procedures for Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop, which is another recommended Improvement Activity. | Medium |
| Care Transition Documentation Practice Improvements | Use Direct messaging, C-CDA import and export, phone encounters, and patient chart notes to document practices/processes for care transition. | Medium |
| Consultation of the Prescription Drug Monitoring Program | NextGen Office EHR is integrated with Bamboo Health. It is very common for providers to be engaging with a PDMP already. Many providers may already have access to an PDMP in their area. This is bonus measure for the Promoting Interoperability e-Prescribing measure. | High |
| Depression Screening | This activity directly relates to CMS2: Preventive Care and Screening: Screening for Depression and Follow-Up Plan, which is a Quality measure that a number of our providers already track. Track this eCQM in the Health Measures module. | Medium |
| Engagement of Patients, Family, and Caregivers in Developing a Plan of Care | Use Longitudinal Care Plan to engage patients, family, and caregivers in developing a plan of care. | Medium |
| Engagement of Patients through Implementation of Improvements in Patient Portal | To pass Promoting Interoperability, you must provide patient portal access to the patient. Subscribe to our Premium Patient Portal and you can consider this activity fulfilled.
Set up Patient Messaging and enable Advanced Medical Records Management during the reporting period.
Enable flow sheets for Patient Portal access to help track pertinent health information for chronic conditions. | Medium |
| Implementation of Improvements That Contribute to More Timely Communication of Test Results | Use the Order Status and Orders Log features to document timely communication of test results to patients. | Medium |
| Implementation of Medication Management Practice Improvements | The medication reconciliation component of this activity directly relates to the Promoting Interoperability measure Health Information Exchange. | Medium |
| Implementation of Methodologies for Improvements in Longitudinal Care Management for High Risk Patients | Use Longitudinal Care Plan, High Risk Assessment (Problem List), and HCC Risk Score (Diagnosis Coding) to provide longitudinal care management to patients at high risk for adverse health outcome or harm. | Medium |
| Implementation of Practices/Processes for Developing Regular Individual Care Plans | Use Longitudinal Care Plan, High Risk Assessment (Problem List), and HCC Risk Score (Diagnosis Coding) to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver. | Medium |
| Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop | This activity directly relates to another recommended Improvement Activity, Care Coordination Agreements That Promote Improvements in Patient Tracking across Settings. Use the Orders Log to track patients referred to specialists through the entire process, which is a requirement of Care Coordination Agreements, by confirming the consult order has been resulted. The result should contain the specialists' findings and plan of care.
This activity directly relates to the Quality measure CMS50: Closing the Referral Loop: Receipt of Specialist Report. Track this eCQM in the Health Measures module. | Medium |
| Population Empanelment | Associate a provider with a patient in Associations during the patient registration process. This field reports in the Patient report.
You can manage a patient's internal care team. | Medium |
| Practice Improvements That Engage Community Resources to Support Patient Health Goals | As you work with patients on their health goals, you can provide them with possible community-based programs or resources that they can use to achieve their goals. Maintain a list or provide a guide of available community-based resources. | Medium |
| Regular Review Practices in Place on Targeted Patient Population Needs | Use Quality measure numerator and denominator patient lists to target patient populations (e.g., diabetes). Track this measure in the Health Measures module. | Medium |
| Tobacco Use | This activity directly relates to CMS138: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention, which is a Quality measure most practices score well in. Track this eCQM in the Health Measures module. | Medium |
| Use of Decision Support and Standardized Treatment Protocols | Enable Health Measures Quality measures. You can enable the clinical decision support EHR role in Administration: User Maintenance. | Medium |
Export JSON Files for an Individual Provider
- In EHR, on the bottom toolbar, select Documents.
- Select the My Reports > QPP Reporting.
- Select Export.
- Select a Provider.
- Select a Reporting Period.
- Select All Enrolled Measures.
- Select EXPORT ALL.
- Select an export option.
- IA Individual includes only Improvement Activities.
- QPP Quality + IA Individual includes both Quality measures (eCQMS) and Improvement Activities.
- See QPP API Integration for the next steps.
The QPP report will be available from My Reports by the next day, however, you can check to see if the report is available sooner.
Export QRDA Files for All Providers
Note: Ensure providers are all enrolled in the same program for the same enrollment period (refer to Administration: EHR Reporting and Quality Measures).
- In EHR, on the bottom toolbar, select Documents.
- Select the My Reports > QPP Reporting.
- Select Export.
- Select All Providers.
A confirmation message appears stating that reviewing or exporting patients for all providers can take up to 15 minutes.
- Select Confirm.
- Select a Reporting Period.
- Select All Enrolled Measures.
- Select EXPORT ALL.
- Select QPP Quality + IA Group.
- See QPP API Integration for the next steps.
The Group Report Details window opens. Select the Billing Provider. Optionally, for CPC+, enter the APM Entity ID. Select Export.
The QPP report will be available from My Reports by the next day, however, you can check to see if the report is available sooner.
QPP API Integration
NextGen® Office EHR is integrated with the QPP API for MIPS Improvement Activities attestation.
- Select My Reports. The QPP report is a JSON file.
- Select
.
The CMS login page opens in a new browser tab.
- Log in with your QPP credentials.
A login success message appears.
- Return to My Reports to submit the file. Select
. - Select Confirm.
A file submission success message appears.
Switch Users
If you need to submit a file for a different user, select Switch Users, which ends the existing user session. The CMS login page opens in a new browser tab so you can log in with the new user.
See Also: Improvement Activities Document Management
