Kentucky REC News


For 2020, Kentucky REC Quality experts are hosting a *series of three webinars in which they will discuss each of the four MIPS categories, starting with a deep dive into the Quality category. This category carries not only the highest weight of the four, but also has the longest reporting period.

Strong performance in the Quality category is essential to avoiding the negative payment adjustment. It is also has the biggest impact on your potential for exceptional performance status, which requires a score of 85+ points, and qualifies you for an additional positive payment adjustment factor outside the budget neutral program.

Our experts will share the changes to Quality for 2020, and how ongoing monitoring and improvement is essential in your overall success in the Quality Payment Program. During this first webinar of the series we will discuss ways you can be successful in the Quality performance category and maximize your performance in Program Year 4 no matter your practice size, level of submission, or method of collection. We want to help you not only meet the minimum threshold, but thrive in the Quality Payment Program.

Webinar – QPP Categories Year 4: Quality
Thursday, March 19, 2020 12:30 PM ET
Next in the series:
May 21 – QPP Categories Year 4: Cost
July 16 – QPP Categories Year 4: Promoting Interoperability & Improvement Activities

All QPP Webinars start at 12:30 PM ET

*This webinar is for Kentucky REC contracted QPP clients only. If you are interested in this topic and would like to learn more about becoming a client, please contact us at (859) 323-3090 or Kentucky REC. We aim to be your trusted healthcare advisor!

Future dates subject to change


Assessing the vulnerabilities of your network and IT assets is essential for understanding the risks facing your organization. The Center for Internet Security (CIS) ranks vulnerability assessment third in its 20 critical security controls for effective cyberdefense (CIS Controls).

“Organizations that do not scan for vulnerabilities and proactively address discovered flaws face a significant likelihood of having their computer systems compromised.” *

What is a vulnerability assessment?

A vulnerability assessment is broken down into two different phases:

  • Scanning & diagnosis
  • Results assessment

Scanning & Diagnosis: Our IT expert will use a network scanning device to identify potential points of exploitation on a network or computer and identify security holes within that system. The scanner’s repository of vulnerabilities is updated just before every scan to include any newly identified items, and is compatible with the Common Vulnerabilities and Exposures (CVE) Index, which standardizes the names of vulnerabilities across diverse security products and vendors.

Results Assessment: Once these items are identified, a severity rating is assigned as follows: critical; severe; moderate; or clean. From the severity rating, a mitigation strategy is created to address the most critical items first, and then move down the list in severity level. This mitigation strategy will include information about specific software patches, downloadable fixes and reference content about security weaknesses.

To better facilitate HIPAA compliance in your organization, you should accompany your vulnerability scan with a full Security Risk Analysis and HIPAA Security Education for your staff.

Join our webinar to learn more about these important HIPAA Privacy and Security Topics.

Webinar – HIPAA Security: Find Vulnerabilities Before Attackers Do

Thursday, March 26, 2020 12:00 PM ET


Call 859-323-3090 or email Kentucky REC HIPAA Privacy and Security experts with your questions, or if you want to talk to a security expert to schedule your vulnerability assessment.

Additional Resources:
Center for Internet Security (CIS) Controls List
MITRE Corporation’s Common Vulnerabilities and Exposures



With the start of 2020, we have a new set of rules and guidelines to implement for the Quality Payment Program Year 4! At the same time, we are now in the submission period for 2019.

Kentucky REC experts will present the biggest impacts of the Final Rule for the Merit Based Incentive Payment System’s (MIPS) four performance categories, highlighting what could affect you and your practice the most. We will also explore the changes to the Alternative Payment Model (APMs) track of the QPP, and what you can expect to see with the future of the program.

MIPS is becoming progressively more difficult to achieve a positive payment incentive as thresholds increase, and as more clinicians aim to better their own performance to avoid the penalties associated with the program. Don’t fall behind in your performance!


Thursday, February 20, 2020 12:30 PM ET


Contact the experts at Kentucky REC for all your QPP, MIPS, and APM questions. We’re here to help: 859-323-3090.


Do you have questions about the benefits of PCMH/PCSP?

Are you wondering how to sustain your recognition?

Join us for an in-depth conversation about recent PCMH and PCSP updates, along with ways to sustain a patient-centered care model through Recognition and Annual Reporting.

Topics include:

  • recognition sustainability
  • quality improvement
  • financial benefits
  • increase staff engagement
  • improve patient satisfaction

Patient-Centered Medical Home (PCMH) and Patient-Centered Specialty Practice (PCSP) are excellent practice transformation models for organizations committed to improving access, communication, and care coordination. NCQA recognized practices succeed in cutting costs, increasing both quality outcomes and patient satisfaction. Now is the perfect time to pursue recognition since your organization can also receive full points in the Improvement Activities category of the Quality Payment Program (QPP) Merit-Based Incentive Payment System (MIPS) under the Medicare Access and CHIP Reauthorization Act (MACRA).

Thursday March 5, 12-1 p.m. ET

Contact us at Kentucky REC with your questions about PCMH and PCSP. Our team of experts is here to help: 859-323-3090.


In order to successfully meet the objectives of Stage 3 Medicaid Promoting Interoperability, it is crucial for you to be looking at the 2020 requirements.

During the webinar we will review the Stage 3 objectives and the thresholds for each measure. We will provide detailed information regarding the newest measures and the importance of having a 2015 CEHRT.

Let Kentucky REC advisors help you be prepared and successful when tackling Stage 3. We will provide action lists that will guide you through the important next steps to meeting the thresholds for hard to reach measures.

Webinar: KY Medicaid Promoting Interoperability (MU) 2020 Stage 3 Overview for Eligible Professionals

Wednesday, March 25, 2020 12:00 pm ET


Contact us at Kentucky REC with your questions about Promoting Interoperability. Our team of experts is here to help: 859-323-3090.


Our partners at the Kentucky Health Information Exchange are excited to announce the launch of their Provider Assistance Program mini-grant opportunity.

In collaboration with the Department for Medicaid Services (DMS) and Centers for Medicare & Medicaid Services (CMS), the Kentucky Health Information Exchange (KHIE) is offering Pharmacies, Eligible Providers (EPs), Eligible Hospitals (EHs) and Critical Access Hospitals (CAHs) the opportunity to apply for a mini-grant to offset the vendor fees associated with connecting to KHIE.

The Provider Assistance Program was created to help Pharmacies, EPs, EHs and CAHs in rural areas of the state to mitigate the challenges associated with interoperability. The objective is to relieve some of the financial burden a healthcare facility experiences which hinders engagement in Public Health and Clinical Data Registry reporting as well as Health Information Exchange.

Applicants are required to be:

  • located in the state of Kentucky
  • considered an EP, EH or CAH (as defined by CMS)
  • or a licensed pharmacy

If approved, EHs and CAHs may be awarded up to $15,000 and Pharmacies and EPs may be awarded up to $8,000.

Grants will be awarded on a first come first serve basis until all grant funds are depleted. Incomplete applications will not be considered and only one grant will be awarded per business entity.

If interested, please complete the Provider Assistance Program Application in its entirety and e-mail to Brett Brown ( with the subject line: Application for the Provider Assistance Program.

Applications can also be found on the KHIE Website.

Applications will be accepted through June 30, 2020.


Kentucky REC Quality Manager Robin Huffman, and Quality Advisors Jessica Elliott, Brent Doom, Kelly Fountain, Megan McIntosh, Kristen Gardner, Rebecca Cheatham, and Vance Drakeford, along with Stephanie Durbin, a Clinical Quality Specialist Manager, have been working with 75 ambulatory dyad pairs in primary and specialty care clinics at UK HealthCare. Since March 2019, our advisors have hosted monthly in-person Ambulatory Dyad Quality Collaboratives. They also provide ongoing advice and resources to the dyads (each made up of a physician lead and a practice manager) in choosing targets for improvement and implementing real change within their clinics.

With guidance on change management and other quality improvement tools, the ambulatory clinic teams have seen improvements such as reductions in no-show rates, reducing patient wait times, score increases in care coordination, retained questions, and more. The article discusses a fall 2019 meeting that featured poster presentations, where eight teams were selected to share their improvements with the rest of the collaborative members.

You can read the full article here.

Contact our Quality Improvement Advisors at Kentucky REC for all your quality improvement questions. We’re here to help: 859-323-3090.


The deadline to submit 2019 data for the CMS Medicare Promoting Interoperability Program is March 2, 2020.

CMS transitioned to the QualityNet System (also known as CMS’s Hospital Quality Reporting [HQR] system) in 2018 for hospitals that attest to CMS for the Medicare Promoting Interoperability Program. By transitioning to one system, CMS continues their effort to streamline data submission methods.

QualityNet Secure Portal
Eligible Hospital Information Webpage
QualityNet Secure Portal Enrollment and Login User Guide

Visit the Registration and Attestation page on the CMS Promoting Interoperability Programs website.

Please contact the Kentucky Regional Extension Center for assistance with reviewing your Stage 3 reports, or with any questions you may have regarding the attestation process, or suggested documents to retain.

Contact the experts at Kentucky REC with your questions about the Promoting Interoperability Program. Our team of experts is here to help: 859-323-3090.


Focus on Care Coordination – Improving Patient Outcomes, Reducing ER Visits & Hospital Readmissions

The Methodist Physician Group (MPG) is a hospital-based organization with locations in three counties in Western Kentucky. MPG is comprised of acute and ambulatory services that include various multi-specialties. They see nearly 10,000 patients per month at 18 clinics, plus a same day clinic.

Sue Ginn, RN, is the Quality Improvement Specialist and Analyst, and heads their Quality Improvement team. The team members are comprised of clinical, IT, and administrative staff. Team members include: Amy Scales, Tiffany Smith, Jenny Phillips, Chanda Smock, Christy Stone, Scott Lutz, Janet Burnett, and Todd Duckworth. Vance Drakeford of Kentucky REC serves as the Quality Improvement Advisor for the practice. They have concentrated their efforts on building a Quality Improvement team and engaging clinicians and staff in quality improvement activities. This has been the intervention responsible for much of their success. MPG brings value to their patients through improved outcomes, care coordination, patient experience, and reduction of costs associated with care. This driving force places Methodist Physician Group in a position to be highly successful in various value-based payment models.

Performance Area Highlights

Beginning in November 2015, a pilot Care Coordination role was added to the MPG team at one of their primary care locations, and soon after another location was added to their responsibility. The goal for the Care Coordination role was to help reduce risk of readmissions, ER visits and facilitate follow-up care with patients’ primary care providers. This has led patients to improved understanding of their conditions, comorbidities, treatment and health goals.

Their high level of care coordination has resulted in a decrease of their 30 day Hospital Readmissions, showing a 0.80% improvement from 2017 to 2018. Specific patient populations have seen even higher reductions in the 30 day Hospital Readmission rates: Acute Myocardial Infarction = 1.5%, and COPD = 4.50%. Total Knee and Hip Arthroplasty had a 2% increase; however, they were 1% below the Expected All Cause Readmit rate. This is a 1.2% improvement on being below the Expected All Cause Readmit rate from 2017.

Additionally, their care coordination has led to a reduction in ER visits from 2017 to 2018. ER visit reduction has led to an estimated cost savings of $983,180.00 based off adjustment of total patient population, and CMS’s average cost of $902.00 per ER visit.

These reductions are credited to MPGs dedication to comprehensive, patient-centered care that has proven to decrease hospital readmissions and ER visits.

The MPG Care Coordinators review the daily hospital and ER discharge lists, and then call discharged patients to discuss the following:

    • Check on their current conditions
    • Confirm follow-up appointments
    • Verify appropriate medication has been received
    • Verify medication education understood


These actions have proven to be the most effective factors for the 30 day hospital readmission reduction and decreased number of ER visits.

Key Success Factors

Not only has the team seen reductions in 30 day hospital readmissions and ER visits, but the staff has gained satisfaction in the “little things” by helping patients with such things as: transportation assistance to appointments; diagnosis education; self-management with their diagnoses; coordination with various local agencies; and coordination with case management companies for other medical referrals to ensure patients receive the best care available.

MPG has added a total of five Care Coordination roles to their team since they began in late 2015 due to the success of this effort. These roles now include Medicare Gap and Medicare Wellness Appointments. This has helped improve the health of their patients, and helped catch abnormalities early by encouraging patients to have preventive screenings completed. Their work has not only helped keep patients out of the hospital, but it has also integrated an entire patient focus, improving the overall wellness of and care for their community and patient population.

We asked members of the MPG team questions regarding their experience with practice transformation. Here are some of their answers.

What’s the #1 thing you’ve gotten from your four years of practice transformation work?

Sue answered, “After the first conference I came back thinking ‘OMG what have I gotten into, it’s the tiger by the tail and the tiger has me!’ With the help of KYREC, it was still hairy scary, with a lot of work, but less intimidating because we could go to (Kentucky REC Quality Advisors) Vance, Robin, and Kelly for help.”

“I knew cost was always important, but thought of it in regard to patient affordability until working with KYREC. Now I understand the impact of cost on the healthcare organization, and the payers.”

How did you choose to focus on care transitions, particularly your hospital readmission rates?

Sue answered, “In 2015 the hospital was taking a hit with 30 day readmission rates, it’s bad for the bottom line and staying in the black. We had a restructuring in MPG – to add a care coordinator under a trial basis; we saw the advantage of it with just a couple providers, decided to move forward with other practices. We had a high number of readmits and avoidables at the beginning. Then we hired a care coordinator, and it just turned into more.”

“It was definitely worth it! The goal for the nurses is the outcome of the patient. The administration is looking at the financial bottom line, for us patient care is absolutely #1. We see clinical outcomes. With these changes, all sides benefit.”

“We saw the benefit it would make to our patients and in the community. Healthier patients, better community!”

Contact our Quality Improvement Advisors at Kentucky REC for all your quality improvement questions. We’re here to help: 859-323-3090.


The QPP Resource Center for CMS designated small practices (fewer than 15 clinicians) now offers a Qualified Registry to users of the Resource Center Portal. Eligible clinicians can use MIPScast® Qualified Registry to submit their data to CMS.

Read through the 2019 Participation Guide for an overview, explanation, and reasons to consider using MIPScast® as a Qualified Registry for reporting to CMS. It also includes registration steps, how to access the necessary consent forms through the portal, and important dates to keep in mind.

Reasons to Consider Using MIPScast® QR for Reporting to CMS:
You may want to use the MIPScast® QR reporting option simply for the convenience of having a trusted partner do the submission work for you, and skip HARP account access requests and connecting to providers to submit data. Perhaps you want the confidence of knowing your data has been reviewed to check for completeness, catch potential validation issues earlier, and that it includes any available reporting options/bonuses that can boost your total score.

Many clinicians are still without the functionality and updated reports from their EHR technology to get the performance data they need for eCQMs and Promoting Interoperability measures. Some will need an alternative to reporting eCQMs from the EHR due to vendor issues including:

  • Vendor having difficulty attaining 2015 certification or using de-certified EHR technology
  • Unable to upgrade and implement 2015 technology in a timely manner due to vendor issues or delays
  • Reporting/data issues (e.g. limited eCQM availability, invalid QRDA 3 reports, inability to produce group-level aggregated reports)
  • Having to acquire and implement additional 3rd party technology to support your functional needs and reporting requirements
  • Cost barriers (e.g. additional costs for eCQM report access, eCQM access bundled with costly data submission services)
  • Difficult eCQM workflows, system configuration, and clinical documentation requirements leading to low performance results

Claims-based reporting for the Quality Performance Category is one alternative, but you have to submit Quality Data Codes (aka “G-codes”) on your Medicare claims throughout the 12-month performance period to get credit. Another alternative is to report through a QR such as MIPScast® , which provides the option to report MIPS CQMs (formerly referred to as “Registry measures”) which can only be collected and submitted by QRs and QCDRs.

Contact the experts at Kentucky REC for all your QPP, MIPS, and APM questions. We’re here to help: 859-323-3090.