NUMERATOR / DENOMINATOR
- DENOMINATOR: Number of unique patients seen by the Eligible Physician (EP) or other eligible professional during the EHR reporting period.
- NUMERATOR: Number of patients in the denominator who have at least one entry or an indication that no problems are known for the patient recorded as structured data in their problem list.
The resulting percentage (Numerator ÷ Denominator) must be more than 80 percent in order for an EP to meet this measure.
- The Medicare and Medicaid EHR Incentive Programs do not specify the use of ICD-9 or SNOMED-CT® in meeting the measure for this objective. However, the Office of the National Coordinator for Health Information Technology (ONC) has adopted ICD-9 or SNOMED-CT® for the entry of structured data for this measure and made this a requirement for EHR technology to be certified. Therefore, Eligible Physicians (EPs) or other eligible professionals will need to maintain an up-to-date problem list of current and active diagnoses using ICD-9 or SNOMED-CT® as a basis for the entry of structured data into certified EHR technology in order to meet the measure for this objective.
- For patients with no current or active diagnoses, an entry must still be made to the problem list indicating that no problems are known.
- An EP is not required to update the problem list at every contact with the patient. The measure ensures the EP has a problem list for patients seen during the EHR reporting period, and that at least one piece of information is presented to the EP. The EP can then use their judgment in deciding what further probing or updating may be required given the clinical circumstances.
- The initial diagnosis can be recorded in lay terms and later converted to standard structured data or can be initially entered using standard structured data.