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"measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_006_Registry.pdf" } }, { "title": "Coronary Artery Disease (CAD): Beta-Blocker Therapy - Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)", "eMeasureId": "CMS145v6", "nqfEMeasureId": null, "nqfId": "0070", "measureId": "007", "description": "Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period who also have a prior MI OR a current or prior LVEF <40% who were prescribed beta-blocker therapy", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "Physician Consortium for Performance Improvement", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "overallAlgorithm": "weightedAverage", "isIcdImpacted": false, 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"S92.041A", "S92.041B", "S92.042A", "S92.042B", "S92.043A", "S92.043B", "S92.044A", "S92.044B", "S92.045A", "S92.045B", "S92.046A", "S92.046B", "S92.051A", "S92.051B", "S92.052A", "S92.052B", "S92.053A", "S92.053B", "S92.054A", "S92.054B", "S92.055A", "S92.055B", "S92.056A", "S92.056B", "S92.061A", "S92.061B", "S92.062A", "S92.062B", "S92.063A", "S92.063B", "S92.064A", "S92.064B", "S92.065A", "S92.065B", "S92.066A", "S92.066B", "S92.101A", "S92.101B", "S92.102A", "S92.102B", "S92.109A", "S92.109B", "S92.111A", "S92.111B", "S92.112A", "S92.112B", "S92.113A", "S92.113B", "S92.114A", "S92.114B", "S92.115A", "S92.115B", "S92.116A", "S92.116B", "S92.121A", "S92.121B", "S92.122A", "S92.122B", "S92.123A", "S92.123B", "S92.124A", "S92.124B", "S92.125A", "S92.125B", "S92.126A", "S92.126B", "S92.131A", "S92.131B", "S92.132A", "S92.132B", "S92.133A", "S92.133B", "S92.134A", "S92.134B", "S92.135A", "S92.135B", "S92.136A", "S92.136B", "S92.141A", "S92.141B", "S92.142A", "S92.142B", "S92.143A", "S92.143B", "S92.144A", "S92.144B", "S92.145A", "S92.145B", "S92.146A", "S92.146B", "S92.151A", "S92.151B", "S92.152A", "S92.152B", "S92.153A", "S92.153B", "S92.154A", "S92.154B", "S92.155A", "S92.155B", "S92.156A", "S92.156B", "S92.191A", "S92.191B", "S92.192A", "S92.192B", "S92.199A", "S92.199B", "S92.201A", "S92.201B", "S92.202A", "S92.202B", "S92.209A", "S92.209B", "S92.211A", "S92.211B", "S92.212A", "S92.212B", "S92.213A", "S92.213B", "S92.214A", "S92.214B", "S92.215A", "S92.215B", "S92.216A", "S92.216B", "S92.221A", "S92.221B", "S92.222A", "S92.222B", "S92.223A", "S92.223B", "S92.224A", "S92.224B", "S92.225A", "S92.225B", "S92.226A", "S92.226B", "S92.231A", "S92.231B", "S92.232A", "S92.232B", "S92.233A", "S92.233B", "S92.234A", "S92.234B", "S92.235A", "S92.235B", "S92.236A", "S92.236B", "S92.241A", "S92.241B", "S92.242A", "S92.242B", "S92.243A", "S92.243B", "S92.244A", "S92.244B", "S92.245A", "S92.245B", "S92.246A", "S92.246B", "S92.251A", "S92.251B", "S92.252A", "S92.252B", "S92.253A", "S92.253B", "S92.254A", "S92.254B", "S92.255A", "S92.255B", "S92.256A", "S92.256B", "S92.301A", "S92.301B", "S92.302A", "S92.302B", "S92.309A", "S92.309B", "S92.311A", "S92.311B", "S92.312A", "S92.312B", "S92.313A", "S92.313B", "S92.314A", "S92.314B", "S92.315A", "S92.315B", "S92.316A", "S92.316B", "S92.321A", "S92.321B", "S92.322A", "S92.322B", "S92.323A", "S92.323B", "S92.324A", "S92.324B", "S92.325A", "S92.325B", "S92.326A", "S92.326B", "S92.331A", "S92.331B", "S92.332A", "S92.332B", "S92.333A", "S92.333B", "S92.334A", "S92.334B", "S92.335A", "S92.335B", "S92.336A", "S92.336B", "S92.341A", "S92.341B", "S92.342A", "S92.342B", "S92.343A", "S92.343B", "S92.344A", "S92.344B", "S92.345A", "S92.345B", "S92.346A", "S92.346B", "S92.351A", "S92.351B", "S92.352A", "S92.352B", "S92.353A", "S92.353B", "S92.354A", "S92.354B", "S92.355A", "S92.355B", "S92.356A", "S92.356B", "S92.811A", "S92.811B", "S92.812A", "S92.812B", "S92.819A", "S92.819B", "S92.901A", "S92.901B", "S92.902A", "S92.902B", "S92.909A", "S92.909B", "S99.001A", "S99.001B", "S99.002A", "S99.002B", "S99.009A", "S99.009B", "S99.011A", "S99.011B", "S99.012A", "S99.012B", "S99.019A", "S99.019B", "S99.021A", "S99.021B", "S99.022A", "S99.022B", "S99.029A", "S99.029B", "S99.031A", "S99.031B", "S99.032A", "S99.032B", "S99.039A", "S99.039B", "S99.041A", "S99.041B", "S99.042A", "S99.042B", "S99.049A", "S99.049B", "S99.091A", "S99.091B", "S99.092A", "S99.092B", "S99.099A", "S99.099B", "S99.101A", "S99.101B", "S99.102A", "S99.102B", "S99.109A", "S99.109B", "S99.111A", "S99.111B", "S99.112A", "S99.112B", "S99.119A", "S99.119B", "S99.121A", "S99.121B", "S99.122A", "S99.122B", "S99.129A", "S99.129B", "S99.131A", "S99.131B", "S99.132A", "S99.132B", "S99.139A", "S99.139B", "S99.141A", "S99.141B", "S99.142A", "S99.142B", "S99.149A", "S99.149B", "S99.191A", "S99.191B", "S99.192A", "S99.192B", "S99.199A", "S99.199B" ], "minAge": 50, "procedureCodes": [ { "code": "22310" }, { "code": "22315" }, { "code": "22318" }, { "code": "22319" }, { "code": "22325" }, { "code": "22326" }, { "code": "22327" }, { "code": "22510" }, { "code": "22511" }, { "code": "22513" }, { "code": "22514" }, { "code": "25600" }, { "code": "25605" }, { "code": "25606" }, { "code": "25607" }, { "code": "25608" }, { "code": "25609" }, { "code": "27230" }, { "code": "27232" }, { "code": "27235" }, { "code": "27236" }, { "code": "27238" }, { "code": "27240" }, { "code": "27244" }, { "code": "27245" }, { "code": "27246" }, { "code": "27248" } ] } ], "performanceOptions": [ { "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9688" } ] }, { "optionType": "performanceMet", "qualityCodes": [ { "code": "5015F", "modifierExclusions": [ "1P", "2P", "3P", "8P" ] } ] }, { "optionType": "performanceNotMet", "qualityCodes": [ { "code": "5015F", "modifierExclusions": [ "1P", "2P", "3P" ], "modifiers": [ "8P" ] } ] } ] }, { "title": "Screening for Osteoporosis for Women Aged 65-85 Years of Age", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0046", "measureId": "039", "description": "Percentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "claims", "registry" ], "measureSets": [ "generalPracticeFamilyMedicine", "internalMedicine", "preventiveMedicine", "rheumatology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_039_Registry.pdf", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_039_Claims.pdf" }, "eligibilityOptions": [ { "diagnosisExclusionCodes": [ "M80.00XA", "M80.00XD", "M80.00XG", "M80.00XK", "M80.00XP", "M80.00XS", "M80.011A", "M80.011D", "M80.011G", "M80.011K", "M80.011P", "M80.011S", "M80.012A", "M80.012D", "M80.012G", "M80.012K", "M80.012P", "M80.012S", "M80.019A", "M80.019D", "M80.019G", "M80.019K", "M80.019P", "M80.019S", "M80.021A", "M80.021D", "M80.021G", "M80.021K", "M80.021P", "M80.021S", "M80.022A", "M80.022D", "M80.022G", "M80.022K", "M80.022P", "M80.022S", "M80.029A", "M80.029D", "M80.029G", "M80.029K", "M80.029P", "M80.029S", "M80.031A", "M80.031D", "M80.031G", "M80.031K", "M80.031P", "M80.031S", "M80.032A", "M80.032D", "M80.032G", "M80.032K", "M80.032P", "M80.032S", "M80.039A", "M80.039D", "M80.039G", "M80.039K", "M80.039P", "M80.039S", "M80.041A", "M80.041D", "M80.041G", "M80.041K", "M80.041P", "M80.041S", "M80.042A", "M80.042D", "M80.042G", "M80.042K", "M80.042P", "M80.042S", "M80.049A", "M80.049D", "M80.049G", "M80.049K", "M80.049P", "M80.049S", "M80.051A", "M80.051D", "M80.051G", "M80.051K", "M80.051P", "M80.051S", "M80.052A", "M80.052D", "M80.052G", "M80.052K", "M80.052P", "M80.052S", "M80.059A", "M80.059D", "M80.059G", "M80.059K", "M80.059P", "M80.059S", "M80.061A", "M80.061D", "M80.061G", "M80.061K", "M80.061P", "M80.061S", "M80.062A", "M80.062D", "M80.062G", "M80.062K", "M80.062P", "M80.062S", "M80.069A", "M80.069D", "M80.069G", "M80.069K", "M80.069P", "M80.069S", "M80.071A", "M80.071D", "M80.071G", "M80.071K", "M80.071P", "M80.071S", "M80.072A", "M80.072D", "M80.072G", "M80.072K", "M80.072P", "M80.072S", "M80.079A", "M80.079D", "M80.079G", "M80.079K", "M80.079P", "M80.079S", "M80.08XA", "M80.08XD", "M80.08XG", "M80.08XK", "M80.08XP", "M80.08XS", "M80.80XA", "M80.80XD", "M80.80XG", "M80.80XK", "M80.80XP", "M80.80XS", "M80.811A", "M80.811D", "M80.811G", "M80.811K", "M80.811P", "M80.811S", "M80.812A", "M80.812D", "M80.812G", "M80.812K", "M80.812P", "M80.812S", "M80.819A", "M80.819D", "M80.819G", "M80.819K", "M80.819P", "M80.819S", "M80.821A", "M80.821D", "M80.821G", "M80.821K", "M80.821P", "M80.821S", "M80.822A", "M80.822D", "M80.822G", "M80.822K", "M80.822P", "M80.822S", "M80.829A", "M80.829D", "M80.829G", "M80.829K", "M80.829P", "M80.829S", "M80.831A", "M80.831D", "M80.831G", "M80.831K", "M80.831P", "M80.831S", "M80.832A", "M80.832D", "M80.832G", "M80.832K", "M80.832P", "M80.832S", "M80.839A", "M80.839D", "M80.839G", "M80.839K", "M80.839P", "M80.839S", "M80.841A", "M80.841D", "M80.841G", "M80.841K", "M80.841P", "M80.841S", "M80.842A", "M80.842D", "M80.842G", "M80.842K", "M80.842P", "M80.842S", "M80.849A", "M80.849D", "M80.849G", "M80.849K", "M80.849P", "M80.849S", "M80.851A", "M80.851D", "M80.851G", "M80.851K", "M80.851P", "M80.851S", "M80.852A", "M80.852D", "M80.852G", "M80.852K", "M80.852P", "M80.852S", "M80.859A", "M80.859D", "M80.859G", "M80.859K", "M80.859P", "M80.859S", "M80.861A", "M80.861D", "M80.861G", "M80.861K", "M80.861P", "M80.861S", "M80.862A", "M80.862D", "M80.862G", "M80.862K", "M80.862P", "M80.862S", "M80.869A", "M80.869D", "M80.869G", "M80.869K", "M80.869P", "M80.869S", "M80.871A", "M80.871D", "M80.871G", "M80.871K", "M80.871P", "M80.871S", "M80.872A", "M80.872D", "M80.872G", "M80.872K", "M80.872P", "M80.872S", "M80.879A", "M80.879D", "M80.879G", "M80.879K", "M80.879P", "M80.879S", "M80.88XA", "M80.88XD", "M80.88XG", "M80.88XK", "M80.88XP", "M80.88XS", "M81.0", "M81.6", "M81.8" ], "maxAge": 85, "minAge": 65, "procedureCodes": [ { "code": "99201" }, { "code": "99202" }, { "code": "99203" }, { "code": "99204" }, { "code": "99205" }, { "code": "99212" }, { "code": "99213" }, { "code": "99214" }, { "code": "99215" } ], "sexCode": "F" } ], "performanceOptions": [ { "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9690" } ] }, { "optionType": "performanceMet", "qualityCodes": [ { "code": "G8399" } ] }, { "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8400" } ] } ] }, { "title": "Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0134", "measureId": "043", "description": "Percentage of patients aged 18 years and older undergoing isolated CABG surgery who received an IMA graft", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "Society of Thoracic Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "thoracicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_043_Registry.pdf" } }, { "title": "Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0236", "measureId": "044", "description": "Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_044_Registry.pdf" } }, { "title": "Medication Reconciliation Post-Discharge", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0097", "measureId": "046", "description": "The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record.\rThis measure is reported as three rates stratified by age group:\r- Submission Criteria 1: 18-64 years of age\r- Submission Criteria 2: 65 years and older\r- Total Rate: All patients 18 years of age and older", 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"National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "claims", "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "cardiology", "obstetricsGynecology", "vascularSurgery", "thoracicSurgery", "rheumatology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_236_Registry.pdf", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_236_Claims.pdf", "cmsWebInterface": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Web-Interface-Measures/2018_WI_HTN2.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/measures/cms165v6" }, "cpcPlusGroup": "Outcome_Measure", "eMeasureUuid": "40280382-5abd-fa46-015b-49abb28d38b2", "strata": [ { "description": "Patients whose blood pressure at the most recent visit is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "5C206C23-4CF9-4390-9E76-0F243FE59DCF", "denominatorUuid": "1D456B20-71F7-4477-BD23-D39600D5A095", "numeratorUuid": "709D84FA-637D-42CD-8934-43C3FBAD0979", "denominatorExclusionUuid": "9805BC7D-274C-4CCF-916A-B5BA34D62A31" } } ], "eligibilityOptions": [ { "diagnosisCodes": [ "I10" ], "maxAge": 85, "minAge": 18, "procedureCodes": [ { "code": "99201" }, { "code": "99202" }, { "code": "99203" }, { "code": "99204" }, { "code": "99205" }, { "code": "99212" }, { "code": "99213" }, { "code": "99214" }, { "code": "99215" }, { "code": "99341" }, { "code": "99342" }, { "code": "99343" }, { "code": "99344" }, { "code": "99345" }, { "code": "99347" }, { "code": "99348" }, { "code": "99349" }, { "code": "99350" }, { "code": "G0402" }, { "code": "G0438" }, { "code": "G0439" } ] } ], "performanceOptions": [ { "optionType": "performanceMet", "qualityCodes": [ { "code": "G8752" }, { "code": "G8754" } ] }, { "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8753" }, { "code": "G8754" } ] }, { "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8753" }, { "code": "G8755" } ] }, { "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8755" }, { "code": "G8752" } ] }, { "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8756" } ] }, { "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9740" } ] }, { "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9231" } ] }, { "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9910" } ] } ] }, { "title": "Use of High-Risk Medications in the Elderly", "eMeasureId": "CMS156v6", "nqfEMeasureId": null, "nqfId": "0022", "measureId": "238", "description": "Percentage of patients 65 years of age and older who were ordered high-risk medications. Two rates are submitted.\r1) Percentage of patients who were ordered at least one high-risk medication.\r2) Percentage of patients who were ordered at least two of the same high-risk medication", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "overallAlgorithm": "overallStratumOnly", "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "generalPracticeFamilyMedicine", "internalMedicine", "rheumatology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_238_Registry.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/measures/cms156v6" }, "strata": [ { "description": "Patients with an order for at least one high-risk medication during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "82984537-92A9-4546-BDBD-5FF8ED1A0F53", "denominatorUuid": "1786D67F-A917-4948-994A-7238EBFB513E", "numeratorUuid": "C23BC68E-9FB9-4799-9B10-A7DC31339A03", "denominatorExclusionUuid": "A798F397-E73F-48FF-A214-01130FE31B1A" }, "name": "overall" }, { "description": "Patients with at least two orders for the same high-risk medication during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "0B6CB87A-9FC7-4909-85F6-83505F827BCE", "denominatorUuid": "E26E912E-C43F-4412-9495-209C6F83616F", "numeratorUuid": "8B77586E-A421-42C4-A8E2-741FDBCF60B6", "denominatorExclusionUuid": "E349E935-6A6C-40E3-A422-FD1759F9AAF3" }, "name": "2+" } ], "cpcPlusGroup": "Other_Measure", "eMeasureUuid": "40280382-5abd-fa46-015b-49b5b1e638e3" }, { "title": "Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents", "eMeasureId": "CMS155v6", "nqfEMeasureId": null, "nqfId": "0024", "measureId": "239", "description": "Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported.\r\r - Percentage of patients with height, weight, and body mass index (BMI) percentile documentation\r - Percentage of patients with counseling for nutrition\r - Percentage of patients with counseling for physical activity", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "overallAlgorithm": "simpleAverage", "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/measures/cms155v6" }, "strata": [ { "description": "Patients who had a height, weight and body mass index 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Lesions may include: microcalcifications, mammographic or sonographic mass or architectural distortion, focal suspicious abnormalities on magnetic resonance imaging (MRI) or other breast imaging amenable to localization such as positron emission tomography (PET) mammography, or a biopsy marker demarcating site of confirmed pathology as established by previous core biopsy", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "American Society of Breast Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_262_Registry.pdf" } }, { "title": "Preoperative Diagnosis of Breast Cancer", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "263", "description": "The percent of patients undergoing breast cancer operations who obtained the diagnosis of breast cancer preoperatively by a minimally invasive biopsy method", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Society of Breast Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_263_Registry.pdf" } }, { "title": "Sentinel Lymph Node Biopsy for Invasive Breast Cancer", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "264", "description": "The percentage of clinically node negative (clinical stage T1N0M0 or T2N0M0) breast cancer patients before or after neoadjuvant systemic therapy, who undergo a sentinel lymph node (SLN) procedure", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Society of Breast Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_264_Registry.pdf" } }, { "title": "Biopsy Follow-Up", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "265", "description": "Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "American Academy of Dermatology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "dermatology", "obstetricsGynecology", "otolaryngology", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_265_Registry.pdf" } }, { "title": "Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1814", "measureId": "268", "description": "All female patients of childbearing potential (12 - 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "claims", "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_268_Registry.pdf", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_268_Claims.pdf" }, "eligibilityOptions": [ { "diagnosisCodes": [ "G40.A09", "G40.A19", "G40.109", "G40.119", "G40.209", "G40.219", "G40.309", "G40.409", "G40.411", "G40.822", "G40.824", "G40.909" ], "maxAge": 44, "minAge": 12, "procedureCodes": [ { "code": "99201", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99202", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99203", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99204", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99205", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99211", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99212", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99213", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99214", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99215", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] } ], "sexCode": "F" } ], "performanceOptions": [ { "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "4340F", "modifierExclusions": [ "2P", "3P", "8P" ], "modifiers": [ "1P" ] } ] }, { "optionType": "performanceMet", "qualityCodes": [ { "code": "4340F", "modifierExclusions": [ "1P", "2P", "3P", "8P" ] } ] }, { "optionType": "performanceNotMet", "qualityCodes": [ { "code": "4340F", "modifierExclusions": [ "1P", "2P", "3P" ], "modifiers": [ "8P" ] } ] } ] }, { "title": "Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury - Bone Loss Assessment", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "271", "description": "Percentage of patients with an inflammatory bowel disease encounter who were prescribed prednisone equivalents greater than or equal to 10 mg/day for 60 or greater consecutive days or a single prescription equating to 600 mg prednisone or greater for all fills and were documented for risk of bone loss once during the reporting year or the previous calendar year. Individuals who received an assessment for bone loss during the prior or current year are considered adequately screened.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Gastroenterological Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "gastroenterology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_271_Registry.pdf" } }, { "title": "Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "275", "description": "Percentage of patients with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted prior to initiating anti-TNF (tumor necrosis factor) therapy", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Gastroenterological Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "gastroenterology", "infectiousDisease" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_275_Registry.pdf" } }, { "title": "Sleep Apnea: Assessment of Sleep Symptoms", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "276", "description": "Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea that includes documentation of an assessment of sleep symptoms, including presence or absence of snoring and daytime sleepiness", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Sleep Medicine", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "otolaryngology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_276_Registry.pdf" } }, { "title": "Sleep Apnea: Severity Assessment at Initial Diagnosis", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "277", "description": "Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Sleep Medicine", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "otolaryngology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_277_Registry.pdf" } }, { "title": "Sleep Apnea: Positive Airway Pressure Therapy Prescribed", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "278", "description": "Percentage of patients aged 18 years and older with a diagnosis of moderate or severe obstructive sleep apnea who were prescribed positive airway pressure therapy", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Sleep Medicine", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "otolaryngology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_278_Registry.pdf" } }, { "title": "Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "279", "description": "Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Sleep Medicine", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "otolaryngology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_279_Registry.pdf" } }, { "title": "Dementia: Cognitive Assessment", "eMeasureId": "CMS149v6", "nqfEMeasureId": null, "nqfId": "2872", "measureId": "281", "description": "Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "Physician Consortium for Performance Improvement", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "neurology", "mentalBehavioralHealth" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/measures/cms149v6" }, "cpcPlusGroup": "Other_Measure", "eMeasureUuid": "40280382-5971-4eed-015a-4e002d4b4b66", "strata": [ { "description": "Patients for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period", "eMeasureUuids": { "initialPopulationUuid": "E86E2FC5-8F1F-44ED-B30D-FA66D200B1C7", "denominatorUuid": "E7337FE2-42EF-467C-9981-BF1D1F489357", "numeratorUuid": "9B6325F1-07B8-4B1C-AF92-4F4F1269C234", "denominatorExceptionUuid": "EE1F4525-BB1F-4299-A802-E74A297D58A7" } } ] }, { "title": "Dementia: Functional Status Assessment", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "282", "description": "Percentage of patients with dementia for whom an assessment of functional status* was performed at least once in the last 12 months", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "neurology", "mentalBehavioralHealth" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_282_Registry.pdf" } }, { "title": "Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "283", "description": "Percentage of patients with dementia for whom there was a documented symptoms screening* for behavioral and psychiatric symptoms, including depression, AND for whom, if symptoms screening was positive, there was also documentation of recommendations for symptoms management in the last 12 months", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "neurology", "mentalBehavioralHealth" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_283_Registry.pdf" } }, { "title": "Dementia: Safety Concerns Screening and Mitigation Recommendations or Referral for Patients with Dementia", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "286", "description": "Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening * in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources or orders for home safety evaluation", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "neurology", "mentalBehavioralHealth" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_286_Registry.pdf" } }, { "title": "Dementia: Caregiver Education and Support", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "288", "description": "Percentage of patients with dementia whose caregiver(s)* were provided with education** on dementia disease management and health behavior changes AND were referred to additional resources*** for support in the last 12 months", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "neurology", "mentalBehavioralHealth" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_288_Registry.pdf" } }, { "title": "Parkinson's Disease: Psychiatric Symptoms Assessment for Patients with Parkinson's Disease", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "290", "description": "Percentage of all patients with a diagnosis of Parkinson's Disease [PD] who were assessed* for psychiatric symptoms** in the past 12 months", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_290_Registry.pdf" } }, { "title": "Parkinson's Disease: Cognitive Impairment or Dysfunction Assessment", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "291", "description": "Percentage of all patients with a diagnosis of Parkinson's Disease [PD] who were assessed* for cognitive impairment or dysfunction in the past 12 months", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_291_Registry.pdf" } }, { "title": "Parkinson's Disease: Rehabilitative Therapy Options", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "293", "description": "Percentage of all patients with a diagnosis of Parkinson's Disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (e.g., physical, occupational, or speech therapy) discussed in the past 12 months", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_293_Registry.pdf" } }, { "title": "Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1536", "measureId": "303", "description": "Percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery, based on completing a pre-operative and post-operative visual function survey", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "primarySteward": "American Academy of Ophthalmology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_303_Registry.pdf" } }, { "title": "Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "304", "description": "Percentage of patients aged 18 years and older who had cataract surgery and were satisfied with their care within 90 days following the cataract surgery, based on completion of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "primarySteward": "American Academy of Ophthalmology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_304_Registry.pdf" } }, { "title": "Initiation and Engagement of Alcohol and Other Drug Dependence Treatment", "eMeasureId": "CMS137v6", "nqfEMeasureId": null, "nqfId": "0004", "measureId": "305", "description": "Percentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported.\ra. Percentage of patients who initiated treatment within 14 days of the diagnosis\rb. Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "overallAlgorithm": "simpleAverage", "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "generalPracticeFamilyMedicine", "internalMedicine", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/measures/cms137v6" }, "strata": [ { "description": "Patients who initiated treatment within 14 days of the diagnosis", "eMeasureUuids": { "initialPopulationUuid": "E6569B35-D2C5-464B-A608-BDB2F082FE57", "denominatorUuid": "3F6350CA-654C-4B00-8B62-EC810D1CA790", "numeratorUuid": "6F8814A6-A26A-4FCB-8A41-902971713FCB", "denominatorExclusionUuid": "9242AAE1-D2C4-44A4-AF6B-7DF4C5C9BE31", "strata": [ "F2765AD3-E5E4-40BE-ADCF-E1CCA92B0D42", "C17E38FE-4BC4-46A6-B35D-6F172C4D5F41" ] }, "name": "14DaysOfDiagnosis" }, { "description": "Patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit", "eMeasureUuids": { "initialPopulationUuid": "68E401E4-8CB6-4A5D-A83D-58F8E902E012", "denominatorUuid": "417055BD-AECD-49D5-8FA7-764FF1544611", "numeratorUuid": "431A7185-548C-4F05-B0D3-90108E4AAD57", "denominatorExclusionUuid": "F1AA2B4F-003E-4770-9394-8D465715CC4D", "strata": [ "2D73F57C-3C9A-49CF-B0C0-D0C512C8A10B", "C18A8AFF-E1DC-49E8-B84D-74DDD399A4E2" ] }, "name": "30DaysOfVisit" } ], "cpcPlusGroup": "Other_Measure", "eMeasureUuid": "40280382-5abd-fa46-015b-499c87c0385e" }, { "title": "Cervical Cancer Screening", "eMeasureId": "CMS124v6", "nqfEMeasureId": null, "nqfId": "0032", "measureId": "309", "description": "Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:\r- Women age 21-64 who had cervical cytology performed every 3 years\r- Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "generalPracticeFamilyMedicine", "internalMedicine", "obstetricsGynecology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/measures/cms124v6" }, "cpcPlusGroup": "Other_Measure", "eMeasureUuid": "40280382-5abd-fa46-015b-4989b55937fe", "strata": [ { "description": "Women with one or more screenings for cervical cancer. Appropriate screenings are defined by any one of the following criteria:\n\n- Cervical cytology performed during the measurement period or the two years prior to the measurement period for women who are at least 21 years old at the time of the test\n \n- Cervical cytology/human papillomavirus (HPV) co-testing performed during the measurement period or the four years prior to the measurement period for women who are at least 30 years old at the time of the test", "eMeasureUuids": { "initialPopulationUuid": "DA8343BF-CC74-432C-8791-25A24371E272", "denominatorUuid": "07FEF163-AD9D-49DF-8888-D61059B5A336", "numeratorUuid": "5FB7CF82-66B2-4193-A149-BBC147C3C806", "denominatorExclusionUuid": "6BB7C510-DA0F-4EA6-A1FB-4609DA8C1229" } } ] }, { "title": "Chlamydia Screening for Women", "eMeasureId": "CMS153v6", "nqfEMeasureId": null, "nqfId": "0033", "measureId": "310", "description": "Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "obstetricsGynecology", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/measures/cms153v6" }, "eMeasureUuid": "40280382-5abd-fa46-015b-49a10e7c3878", "strata": [ { "description": "Women with at least one chlamydia test during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "7D3EDBFF-A7B9-453B-9EB4-279FC4AF6493", "denominatorUuid": "77442762-E66F-4E65-96B8-BA8CD34DCC34", "numeratorUuid": "B4D784DA-F274-464D-B10D-B12B468AE5EC", "denominatorExclusionUuid": "08DF11C3-6C40-4B31-AACC-B4B1458AA832", "strata": [ "DC0F4E18-DAEA-4DD7-8D43-44598B364B1C", "20F1049C-E3FC-4A59-AD24-AB1F36B84198" ] } } ] }, { "title": "Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented", "eMeasureId": "CMS22v6", "nqfEMeasureId": null, "nqfId": null, "measureId": "317", "description": "Percentage of patients aged 18 years and older seen during the submitting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "gastroenterology", "dermatology", "emergencyMedicine", "generalPracticeFamilyMedicine", "internalMedicine", "obstetricsGynecology", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "plasticSurgery", "preventiveMedicine", "neurology", "mentalBehavioralHealth", "vascularSurgery", "generalSurgery", "thoracicSurgery", "urology", "generalOncology", "rheumatology", "nephrology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_317_Registry.pdf", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_317_Claims.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/measures/cms022v6" }, "eMeasureUuid": 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"placesOfServiceExclusions": [ "02" ] }, { "code": "99202", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99203", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99204", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99205", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99212", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99213", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99214", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99215", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99281" }, { "code": "99282" }, { "code": "99283" }, { "code": "99284" }, { "code": "99285" }, { "code": "99304" }, { "code": "99305" }, { "code": "99306" }, { "code": "99307", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99308", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99309", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99310", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99318" }, { "code": "99324" }, { "code": "99325" }, { "code": "99326" }, { "code": "99327" }, { "code": "99328" }, { "code": "99334" }, { "code": "99335" }, { "code": "99336" }, { "code": "99337" }, { "code": "99341" }, { "code": "99342" }, { "code": "99343" }, { "code": "99344" }, { "code": "99345" }, { "code": "99347" }, { "code": "99348" }, { "code": "99349" }, { "code": "99350" }, { "code": "99385" }, { "code": "99386" }, { "code": "99387" }, { "code": "99395" }, { "code": "99396" }, { "code": "99397" }, { "code": "D7140" }, { "code": "D7210" }, { "code": "G0101" }, { "code": "G0402" }, { "code": "G0438" }, { "code": "G0439" } ] } ], "performanceOptions": [ { "optionType": "performanceMet", "qualityCodes": [ { "code": "G8783" } ] }, { "optionType": "performanceMet", "qualityCodes": [ { "code": "G8950" } ] }, { "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8785" } ] }, { "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8952" } ] }, { "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9744" } ] }, { "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "G9745" } ] } ] }, { "title": "Falls: Screening for Future Fall Risk", "eMeasureId": "CMS139v6", "nqfEMeasureId": null, "nqfId": "0101", "measureId": "318", "description": "Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "orthopedicSurgery", "nephrology" ], "measureSpecification": { "cmsWebInterface": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Web-Interface-Measures/2018_WI_CARE2.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/measures/cms139v6" }, "cpcPlusGroup": "Other_Measure", "eMeasureUuid": "40280382-5abd-fa46-015b-49b36bf238d7", "strata": [ { "description": "Patients who were screened for future fall risk at least once within the measurement period", "eMeasureUuids": { "initialPopulationUuid": "5D0D869E-9A8B-4707-9C97-03C17F156DD6", "denominatorUuid": "DEEEB2CC-75E7-487B-895C-1102042B7C97", "numeratorUuid": "714CCB1D-9F3F-403E-B636-2F2A38258D31", "denominatorExclusionUuid": "D97B59F6-89D4-4635-8F38-4C8369D1776E" } } ] }, { "title": "Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0658", "measureId": "320", "description": "Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "American Gastroenterological Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "claims", "registry" ], "measureSets": [ "gastroenterology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_320_Registry.pdf", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_320_Claims.pdf" }, "eligibilityOptions": [ { "diagnosisCodes": [ "Z12.11" ], "maxAge": 75, "minAge": 50, "procedureCodes": [ { "code": "44388", "modifierExclusions": [ "52", "53", "73", "74" ] }, { "code": "45378", "modifierExclusions": [ "52", "53", "73", "74" ] }, { "code": "G0121", "modifierExclusions": [ "52", "53", "73", "74" ] } ] } ], "performanceOptions": [ { "optionType": "performanceMet", "qualityCodes": [ { "code": "0528F", "modifierExclusions": [ "1P", "2P", "3P", "8P" ] } ] }, { "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "0528F", "modifierExclusions": [ "2P", "3P", "8P" ], "modifiers": [ "1P" ] } ] }, { "optionType": "performanceNotMet", "qualityCodes": [ { "code": "0528F", "modifierExclusions": [ "1P", "2P", "3P" ], "modifiers": [ "8P" ] } ] } ] }, { "title": "CAHPS for MIPs Clinician/Group Survey", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0005 & 0006", "measureId": "321", "description": "- Getting timely care, appointments, and information;\r- How well providers Communicate;\r- Patient's Rating of Provider;\r- Access to Specialists;\r- Health Promotion & Education;\r- Shared Decision Making;\r- Health Status/Functional Status;\r- Courteous and Helpful Office Staff;\r- Care Coordination; and\r- Stewardship of Patient Resources", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientEngagementExperience", "primarySteward": "Agency for Healthcare Research & Quality", "metricType": "cahps", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine", "internalMedicine" ], "measureSpecification": {} }, { "title": "Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "322", "description": "Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low risk surgery patients 18 years or older for preoperative evaluation during the 12-month submission period", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "primarySteward": "American College of Cardiology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "cardiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_322_Registry.pdf" } }, { "title": "Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "323", "description": "Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular 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null, "nqfId": null, "measureId": "324", "description": "Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "primarySteward": "American College of Cardiology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "cardiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_324_Registry.pdf" } }, { "title": "Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "325", "description": "Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "American Psychiatric Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "mentalBehavioralHealth" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_325_Registry.pdf" } }, { "title": "Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1525", "measureId": "326", "description": "Percentage of patients aged 18 years and older with nonvalvular atrial fibrillation (AF) or atrial flutter who were prescribed warfarin OR another FDA- approved anticoagulant drug for the prevention of thromboembolism during the measurement period", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American 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"https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_352_Registry.pdf" } }, { "title": "Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "353", "description": "Percentage of patients regardless of age undergoing a total knee replacement whose operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of each prosthetic implant", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "American Association of Hip and Knee Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_353_Registry.pdf" } }, { "title": "Anastomotic Leak Intervention", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "354", "description": "Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "primarySteward": "American College of Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_354_Registry.pdf" } }, { "title": "Unplanned Reoperation within the 30 Day Postoperative Period", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "355", "description": "Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "primarySteward": "American College of Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "plasticSurgery", "generalSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_355_Registry.pdf" } }, { "title": "Unplanned Hospital Readmission within 30 Days of Principal Procedure", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "356", "description": "Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "American College of Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "plasticSurgery", "generalSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_356_Registry.pdf" } }, { "title": "Surgical Site Infection (SSI)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "357", "description": "Percentage of patients aged 18 years and older who had a surgical site infection (SSI)", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "American College of Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "otolaryngology", "plasticSurgery", "vascularSurgery", "generalSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_357_Registry.pdf" } }, { "title": "Patient-Centered Surgical Risk Assessment and Communication", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "358", "description": "Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "process", "primarySteward": "American College of Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "otolaryngology", "plasticSurgery", "vascularSurgery", "generalSurgery", "thoracicSurgery", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_358_Registry.pdf" } }, { "title": "Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "359", "description": "Percentage of computed tomography (CT) imaging reports for all patients, regardless of age, with the imaging study named according to a standardized nomenclature and the standardized nomenclature is used in institution's computer systems", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "American College of Radiology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_359_Registry.pdf" } }, { "title": "Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "360", "description": "Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "American College of Radiology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_360_Registry.pdf" } }, { "title": "Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "361", "description": "Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that are reported to a radiation dose index registry that is capable of collecting at a minimum selected data elements", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "structure", "primarySteward": "American College of Radiology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_361_Registry.pdf" } }, { "title": "Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "362", "description": "Percentage of final reports for computed tomography (CT) studies performed for all patients, regardless of age, which document that Digital Imaging and Communications in Medicine (DICOM) format image data are available to non-affiliated external healthcare facilities or entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "structure", "primarySteward": "American College of Radiology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_362_Registry.pdf" } }, { "title": "Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "363", "description": "Percentage of final reports of computed tomography (CT) studies performed for all patients, regardless of age, which document that a search for Digital Imaging and Communications in Medicine (DICOM) format images was conducted for prior patient CT imaging studies completed at non-affiliated external healthcare facilities or entities within the past 12-months and are available through a secure, authorized, media-free, shared archive prior to an imaging study being performed", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "structure", "primarySteward": "American College of Radiology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_363_Registry.pdf" } }, { "title": "Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "364", "description": "Percentage of final reports for computed tomography (CT) imaging studies of the thorax for patients aged 18 years and older with documented follow-up recommendations for incidentally detected pulmonary nodules (e.g., follow-up CT imaging studies needed or that no follow-up is needed) based at a minimum on nodule size AND patient risk factors", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "American College of Radiology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_364_Registry.pdf" } }, { "title": "Follow-Up Care for Children Prescribed ADHD Medication (ADD)", "eMeasureId": "CMS136v7", "nqfEMeasureId": null, "nqfId": "0108", "measureId": "366", "description": "Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported.\ra. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase\rb. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "overallAlgorithm": "simpleAverage", "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "pediatrics", "mentalBehavioralHealth" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/measures/cms136v7" }, "strata": [ { "description": "Patients who had at least one face-to-face visit with a practitioner with prescribing authority within 30 days after the IPSD.", "eMeasureUuids": { "initialPopulationUuid": "FED976AC-8C91-473B-8E93-61809F442F23", "denominatorUuid": "7872B69D-A1EB-42B3-8ED8-3BF847CC1B0C", "numeratorUuid": "40ADC4A8-3EF2-4672-B287-A5C70C125709", "denominatorExclusionUuid": "0A5E78D7-074C-46C6-9529-56E06681EABA" }, "name": "visitWithin30Days" }, { "description": "Patients who had at least one face-to-face visit with a practitioner with prescribing authority during the Initiation Phase, and at least two follow-up visits during the Continuation and Maintenance Phase. One of the two visits during the Continuation and Maintenance Phase may be a telephone visit with a practitioner.", "eMeasureUuids": { "initialPopulationUuid": "CFB7C953-715D-46BF-9F0D-FE8A25B2A247", "denominatorUuid": "787F0CCC-18DA-4F36-B8DA-F24FB75B0E1C", "numeratorUuid": "B8E236A4-1AE9-44F9-8664-28A6BED54CF8", "denominatorExclusionUuid": "37CC8B9D-0299-4221-8AD6-5B4EC842959B" }, "name": "visitAndFollowups" } ], "eMeasureUuid": "40280382-5abd-fa46-015b-499a7b553852" }, { "title": "Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use", "eMeasureId": "CMS169v6", "nqfEMeasureId": null, "nqfId": null, "measureId": "367", "description": "Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "Center for Quality Assessment and Improvement in Mental Health", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "mentalBehavioralHealth" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/measures/cms169v6" }, "eMeasureUuid": "40280382-5971-4eed-015a-05ec53bb2fc6", "strata": [ { "description": "Patients in the denominator with evidence of an assessment for alcohol or other substance use following or concurrent with the new diagnosis, and prior to or concurrent with the initiation of treatment for that diagnosis", "eMeasureUuids": { "initialPopulationUuid": "16DB7A4E-44E1-4D12-8C0E-6FAAF0D31658", "denominatorUuid": "761F55A1-69CD-433A-BB44-ADB78D7EEF95", "numeratorUuid": "6DA14A79-B592-4709-8712-1E25D60FFFFC" } } ] }, { "title": "Pregnant women that had HBsAg testing", "eMeasureId": "CMS158v6", "nqfEMeasureId": null, "nqfId": null, "measureId": "369", "description": "This measure identifies pregnant women who had a HBsAg (hepatitis B) test during their pregnancy", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "OptumInsight", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "obstetricsGynecology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/measures/cms158v6" }, "eMeasureUuid": "40280382-5971-4eed-015a-05e11c482faf", "strata": [ { "description": "Patients who were tested for hepatitis B surface antigen (HBsAg) during pregnancy within 280 days prior to delivery", "eMeasureUuids": { "initialPopulationUuid": "E11AF7FD-A05B-453A-84C3-9D048BFD8911", "denominatorUuid": "854F621E-DAAE-4631-B6B6-C6A7859A9008", "numeratorUuid": "957945A8-CC61-4D05-BEB2-7C2D38838562", "denominatorExceptionUuid": "D8ABBC9F-142E-410F-8D93-BDFFCC072519" } } ] }, { "title": "Depression Remission at Twelve Months", "eMeasureId": "CMS159v6", "nqfEMeasureId": null, "nqfId": "0710", "measureId": "370", "description": "The percentage of patients 18 years of age and or older with major depression or dysthymia who reached remission 12 months (+/- 30 days) after an index visit", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "Minnesota Community Measurement", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "generalPracticeFamilyMedicine", "internalMedicine", "mentalBehavioralHealth" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_370_Registry.pdf", "cmsWebInterface": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Web-Interface-Measures/2018_WI_MH1.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/measures/cms159v6" }, "eMeasureUuid": "40280382-5b4d-eebc-015b-5e984c6a027e", "strata": [ { "description": "Patients who achieved remission at twelve months as demonstrated by a twelve month (+/- 30 days) PHQ-9 score of less than five", "eMeasureUuids": { "initialPopulationUuid": "2CEFA814-C866-4750-B664-131ACA1DF554", "denominatorUuid": "904292C3-B7FE-4CB6-808D-F718C50B7B78", "numeratorUuid": "6D7953F6-DBDA-420C-A866-39A2A0E8EFF4", "denominatorExclusionUuid": "318B44C0-E350-4657-87CC-467DC1D371A8" } } ] }, { "title": "Depression Utilization of the PHQ-9 Tool", "eMeasureId": "CMS160v6", "nqfEMeasureId": null, "nqfId": "0712", "measureId": "371", "description": "The percentage of patients age 18 and older with the diagnosis of major depression or dysthymia who have a completed PHQ-9 during each applicable 4 month period in which there was a qualifying visit", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "Minnesota Community Measurement", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "overallAlgorithm": "weightedAverage", "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "generalPracticeFamilyMedicine", "internalMedicine", "mentalBehavioralHealth" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/measures/cms160v6" }, "strata": [ { "name": "4MonthsOfEnd", "description": "Office visit, Psych visit, or Face to Face Interaction (No ED) within 4 months of the end of the measurement period that leads to a diagnosis of major depression including remission or dysthymia", "eMeasureUuids": { "initialPopulationUuid": "725F4792-0A9A-49CB-8063-9BA1A57270EC", "denominatorUuid": "AFCACA89-68B1-4415-8D48-341237EDEC02", "numeratorUuid": "6E41C227-F801-45AC-8271-0E9325CE1481", "denominatorExclusionUuid": "D71F6E54-6FC7-482A-AFFB-C09C66506EB7" } }, { "name": "4&8MonthsAfterStart", "description": "Office visit, Psych visit, or Face to Face Interaction (No ED) between 4 and 8 months after the start of the measurement period that leads to a diagnosis of major depression including remission or dysthymia", "eMeasureUuids": { "initialPopulationUuid": "A221C073-3EE6-46DE-AD68-98FB62B4590D", "denominatorUuid": "CCF8EF1D-ACEB-4160-BECE-EBC6DE6AC295", "numeratorUuid": "7B13A87F-621F-4682-BE2C-B0900AEF6AE5", "denominatorExclusionUuid": "0271A3BE-3CF8-4E43-8C52-F14CF020E856" } }, { "name": "4MonthsOfStart", "description": "Office visit, Psych visit, or Face to Face Interaction (No ED) within 4 months of the start of the measurement period that leads to a diagnosis of major depression including remission or dysthymia", "eMeasureUuids": { "initialPopulationUuid": "293D5F5C-912E-40AC-9C0D-4840E5F6E2B8", "denominatorUuid": "E31974D3-5AB2-42F5-ACE3-77415D503785", "numeratorUuid": "3948D321-8D57-4F5B-B3E1-3140D4E6CBBB", "denominatorExclusionUuid": "366C029C-D36B-4585-88D8-824C10AEED5E" } } ], "cpcPlusGroup": "Other_Measure", "eMeasureUuid": "40280382-5b4d-eebc-015b-5e87add90267" }, { "title": "Maternal Depression Screening", "eMeasureId": "CMS82v5", "nqfEMeasureId": null, "nqfId": null, "measureId": "372", "description": "The percentage of children who turned 6 months of age during the measurement year, who had a face-to-face visit between the clinician and the child during child's first 6 months, and who had a maternal depression screening for the mother at least once between 0 and 6 months of life", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/measures/cms082v5" }, "eMeasureUuid": "40280382-5abd-fa46-015b-49b2128438cb", "strata": [ { "description": "Children with documentation of maternal screening or treatment for postpartum depression for the mother", "eMeasureUuids": { "initialPopulationUuid": "88D3358E-49E3-40A0-8872-CABEBCFE8815", "denominatorUuid": "E3912B01-76E9-4D2E-804C-DF86665716C1", "numeratorUuid": "E37DACD1-5536-402D-B1CA-A81C2B3295AA" } } ] }, { "title": "Hypertension: Improvement in Blood Pressure", "eMeasureId": "CMS65v7", "nqfEMeasureId": null, "nqfId": null, "measureId": "373", "description": "Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "intermediateOutcome", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "generalPracticeFamilyMedicine", "internalMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/measures/cms065v7" }, "eMeasureUuid": "40280382-5abd-fa46-015b-44ab0b8a3591", "strata": [ { "description": "Patients whose follow-up blood pressure is at least 10 mmHg less than their baseline blood pressure or is adequately controlled.\r\n\r\nIf a follow-up blood pressure reading is not recorded during the measurement year, the patient's blood pressure is assumed \"not improved.\"", "eMeasureUuids": { "initialPopulationUuid": "08266507-3245-44DC-B0F4-FAC725577050", "denominatorUuid": "302E8035-90AB-4811-813B-CA19E90DBB73", "numeratorUuid": "BF4DFC81-C43C-4B94-88DA-A5AC5F92E0B2", "denominatorExclusionUuid": "0C718EB6-B06C-434F-A4E3-813C7560D23A" } } ] }, { "title": "Closing the Referral Loop: Receipt of Specialist Report", "eMeasureId": "CMS50v6", "nqfEMeasureId": null, "nqfId": null, "measureId": "374", "description": "Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "gastroenterology", "dermatology", "generalPracticeFamilyMedicine", "internalMedicine", "obstetricsGynecology", "ophthalmology", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "preventiveMedicine", "neurology", "mentalBehavioralHealth", "interventionalRadiology", "vascularSurgery", "generalSurgery", "thoracicSurgery", "urology", "generalOncology", "rheumatology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_374_Registry.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/measures/cms050v6" }, "cpcPlusGroup": "Other_Measure", "eMeasureUuid": "40280382-5971-4eed-015a-5c465a344ded", "strata": [ { "description": "Number of patients with a referral, for which the referring provider received a report from the provider to whom the patient was referred", "eMeasureUuids": { "initialPopulationUuid": "3F74FDF3-7881-4874-B7F9-89E74B320C9E", "denominatorUuid": "218F6923-4DF2-4640-B6EA-08FBA487B099", "numeratorUuid": "B682F9C1-F175-4521-9C22-BF848156DD0A" } } ] }, { "title": "Functional Status Assessment for Total Knee Replacement", "eMeasureId": "CMS66v6", "nqfEMeasureId": null, "nqfId": null, "measureId": "375", "description": "Percentage of patients 18 years of age and older who received an elective primary total knee arthroplasty (TKA) who completed baseline and follow-up patient-reported and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/measures/cms066v6" }, "eMeasureUuid": "40280382-5b4d-eebc-015b-5e9d6d0c0294", "strata": [ { "description": "Patients with patient-reported functional status assessment results (i.e., VR-12, PROMIS-10 Global Health, KOOS) in the 90 days prior to or on the day of primary TKA procedure, and 270 - 365 days after TKA procedure", "eMeasureUuids": { "initialPopulationUuid": "8C809576-E8BD-49F5-9135-ACDDE4D33EC9", "denominatorUuid": "02F99A06-E0DB-4CB5-A682-41E071EE6018", "numeratorUuid": "CB2669D7-DD4C-4EAF-AD97-E4034EC69FD9", "denominatorExclusionUuid": "FF02E58F-CD23-40BD-BD15-B6C29FA4840E" } } ] }, { "title": "Functional Status Assessment for Total Hip Replacement", "eMeasureId": "CMS56v6", "nqfEMeasureId": null, "nqfId": null, "measureId": "376", "description": "Percentage of patients 18 years of age and older who received an elective primary total hip arthroplasty (THA) who completed baseline and follow-up patient-reported and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/measures/cms056v6" }, "eMeasureUuid": "40280382-5abd-fa46-015b-49498b373799", "strata": [ { "description": "Patients with patient-reported functional status assessment (i.e., VR-12, PROMIS-10-Global Health, HOOS) in the 90 days prior to or on the day of primary THA procedure, and 270 - 365 days after THA procedure", "eMeasureUuids": { "initialPopulationUuid": "96A28848-59E1-4260-972C-8D7A778F1369", "denominatorUuid": "79CE2ACA-B55F-444F-9717-5A62AFDE4506", "numeratorUuid": "A372B0DB-A50F-475A-99BC-25F1D92E8047", "denominatorExclusionUuid": "2B68371A-2D92-465E-8D28-826893056E9C" } } ] }, { "title": "Functional Status Assessments for Congestive Heart Failure", "eMeasureId": "CMS90v7", "nqfEMeasureId": null, "nqfId": null, "measureId": "377", "description": "Percentage of patients 18 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessments", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "generalPracticeFamilyMedicine", "internalMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/measures/cms090v7" }, "eMeasureUuid": "40280382-5abd-fa46-015b-4434ffa43547", "strata": [ { "description": "Patients with patient-reported functional status assessment results (eg, VR-12; VR-36; MLHF-Q; KCCQ; PROMIS-10 Global Health, PROMIS-29) present in the EHR two weeks before or during the initial FSA encounter and results for the follow-up FSA at least 30 days but no more than 180 days after the initial functional status assessment", "eMeasureUuids": { "initialPopulationUuid": "B4510F26-AA43-4CA6-BEE6-71B33D1A70E6", "denominatorUuid": "51B0D520-BADF-4238-BE65-2C02B69141EB", "numeratorUuid": "45784D8D-B471-401B-A5CE-13F429F20C57", "denominatorExclusionUuid": "6C64B69F-C8EF-4E16-88FB-B03502937883" } } ] }, { "title": "Children Who Have Dental Decay or Cavities", "eMeasureId": "CMS75v6", "nqfEMeasureId": null, "nqfId": null, "measureId": "378", "description": "Percentage of children, age 0-20 years, who have had tooth decay or cavities during the measurement period", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "outcome", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "dentistry" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/measures/cms075v6" }, "eMeasureUuid": "40280382-5abd-fa46-015b-44cef87e35c3", "strata": [ { "description": "Children who had cavities or decayed teeth", "eMeasureUuids": { "initialPopulationUuid": "528EB246-D329-4123-BF93-1C4C5797AA83", "denominatorUuid": "DD411FE5-324C-4715-A898-2126EA30740C", "numeratorUuid": "826C8438-3D6B-494C-89AA-35F3FBE0F73A", "denominatorExclusionUuid": "CF1EE2F3-5133-4AB9-982A-99FFF69BF1E0" } } ] }, { "title": "Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists", "eMeasureId": "CMS74v7", "nqfEMeasureId": null, "nqfId": null, "measureId": "379", "description": "Percentage of children, age 0-20 years, who received a fluoride varnish application during the measurement period", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "pediatrics", "dentistry" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/measures/cms074v7" }, "eMeasureUuid": "40280382-5abd-fa46-015b-48fd374e3757", "strata": [ { "description": "Children who receive a fluoride varnish application", "eMeasureUuids": { "initialPopulationUuid": "A8F19A0F-7823-4446-97FC-F63F0336C30B", "denominatorUuid": "2A3A682E-9300-4F65-B557-F43F0CAEABE2", "numeratorUuid": "1128FA1D-D3CC-4219-AAE9-5656AC629EE1", "denominatorExclusionUuid": "CE323D6E-F6DE-4547-BBE8-2D4BC54CE223", "strata": [ "3214695D-2EAF-43EC-8B40-EF7F8450ED7F", "8CCDE1CC-846B-46A4-B649-498A348FF78E", "D411C97B-9E25-40AF-B386-BD1062428D06" ] } } ] }, { "title": "Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment", "eMeasureId": "CMS177v6", "nqfEMeasureId": null, "nqfId": "1365", "measureId": "382", "description": "Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "Physician Consortium for Performance Improvement", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "pediatrics", "mentalBehavioralHealth" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/measures/cms177v6" }, "eMeasureUuid": "40280382-5a66-eab9-015a-704d816c0247", "strata": [ { "description": "Patient visits with an assessment for suicide risk", "eMeasureUuids": { "initialPopulationUuid": "18350E79-D0CE-4D87-9D70-1D9C74538CA8", "denominatorUuid": "FC8CAC59-A713-4954-AFB0-34A1D786C0C1", "numeratorUuid": "B3FC82CC-C295-4EDB-9C90-3E6A164488E6" } } ] }, { "title": "Adherence to Antipsychotic Medications For Individuals with Schizophrenia", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1879", "measureId": "383", "description": "Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months)", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "intermediateOutcome", "primarySteward": "Health Services Advisory Group", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "generalPracticeFamilyMedicine", "internalMedicine", "mentalBehavioralHealth" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_383_Registry.pdf" } }, { "title": "Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "384", "description": "Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "American Academy of Ophthalmology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_384_Registry.pdf" } }, { "title": "Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "385", "description": "Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "American Academy of Ophthalmology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_385_Registry.pdf" } }, { "title": "Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "386", "description": "Percentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g. advance directives, invasive ventilation, hospice) at least once annually", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_386_Registry.pdf" } }, { "title": "Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "387", "description": "Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12 month reporting period", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "Physician Consortium for Performance Improvement", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "generalPracticeFamilyMedicine", "internalMedicine", "infectiousDisease" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_387_Registry.pdf" } }, { "title": "Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "388", "description": "Percentage of patients aged 18 years and older who had cataract surgery performed and had an unplanned rupture of the posterior capsule requiring vitrectomy", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "primarySteward": "American Academy of Ophthalmology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_388_Registry.pdf" } }, { "title": "Cataract Surgery: Difference Between Planned and Final Refraction", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "389", "description": "Percentage of patients aged 18 years and older who had cataract surgery performed and who achieved a final refraction within +/- 1.0 diopters of their planned (target) refraction", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "American Academy of Ophthalmology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_389_Registry.pdf" } }, { "title": "Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "390", "description": "Percentage of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or other qualified healthcare professional reviewed the range of treatment options appropriate to their genotype and demonstrated a shared decision making approach with the patient. To meet the measure, there must be documentation in the patient record of a discussion between the physician or other qualified healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "process", "primarySteward": "American Gastroenterological Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "gastroenterology", "infectiousDisease" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_390_Registry.pdf" } }, { "title": "Follow-Up After Hospitalization for Mental Illness (FUH)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0576", "measureId": "391", "description": "The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner. Two rates are submitted:\r- The percentage of discharges for which the patient received follow-up within 30 days of discharge.\r- The percentage of discharges for which the patient received follow-up within 7 days of discharge.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "overallAlgorithm": "overallStratumOnly", "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "pediatrics", "mentalBehavioralHealth" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_391_Registry.pdf" }, "strata": [ { "name": "30days", "description": "The percentage of discharges for which the patient received follow-up within 30 days after discharge" }, { "name": "overall", "description": "The percentage of discharges for which the patient received follow-up within 7 days after discharge" } ] }, { "title": "HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2474", "measureId": "392", "description": "Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation This measure is submitted as four rates stratified by age and gender:\r- Submission Age Criteria 1: Females 18-64 years of age\r- Submission Age Criteria 2: Males 18-64 years of age\r- Submission Age Criteria 3: Females 65 years of age and older\r- Submission Age Criteria 4: Males 65 years of age and older", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "primarySteward": "The Heart Rhythm Society", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "overallAlgorithm": "overallStratumOnly", "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "electrophysiologyCardiacSpecialist" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_392_Registry.pdf" }, "strata": [ { "name": "18-64F", "description": "Females 18-64 years of age" }, { "name": "18-64M", "description": "Males 18-64 years of age" }, { "name": "65+F", "description": "Females 65 years of age and older" }, { "name": "65+M", "description": "Males 65 years of age and older" }, { "name": "overall", "description": "Overall percentage of patients with cardiac tamponade and/or pericardiocentesis occurring within 30 days" } ] }, { "title": "HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "393", "description": "Infection rate following CIED device implantation, replacement, or revision", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "primarySteward": "The Heart Rhythm Society", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "electrophysiologyCardiacSpecialist" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_393_Registry.pdf" } }, { "title": "Immunizations for Adolescents", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1407", "measureId": "394", "description": "The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "overallAlgorithm": "overallStratumOnly", "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "generalPracticeFamilyMedicine", "pediatrics", "infectiousDisease" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_394_Registry.pdf" }, "strata": [ { "name": "meningococcal", 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"primarySteward": "Society of Thoracic Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "thoracicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_445_Registry.pdf" } }, { "title": "Operative Mortality Stratified by the Five STS-EACTS Mortality Categories", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0733", "measureId": "446", "description": "Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other 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"https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_456_Registry.pdf" } }, { "title": "Proportion Admitted to Hospice for less than 3 days", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0216", "measureId": "457", "description": "Proportion of patients who died from cancer, and admitted to hospice and spent less than 3 days there", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "American Society of Clinical Oncology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "generalOncology" ], "measureSpecification": { "registry": 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"measureSets": [], "measureSpecification": {} }, { "title": "Average Change in Back Pain following Lumbar Discectomy / Laminotomy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "459", "description": "The average change (preoperative to three months postoperative) in back pain for patients 18 years of age or older who had lumbar discectomy/laminotomy procedure", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "primarySteward": "Minnesota Community Measurement", "metricType": "nonProportion", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "neurosurgical" ], "measureSpecification": { "registry": 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Combination Therapy (Pediatrics)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "463", "description": "Percentage of patients aged 3 through 17 years, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post-operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperatively", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Society of Anesthesiologists", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_463_Registry.pdf" } }, { "title": "Otitis Media with Effusion (OME): Systemic Antimicrobials- Avoidance of Inappropriate Use", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0657", "measureId": "464", "description": "Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials", "nationalQualityStrategyDomain": "Patient Safety, Efficiency and Cost Reduction", "measureType": "process", "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "generalPracticeFamilyMedicine", "otolaryngology", "pediatrics", "infectiousDisease" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_464_Registry.pdf" } }, { "title": "Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and\rInterrogation of Ovarian Arteries", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "465", "description": "The percentage of patients with documentation of angiographic endpoints of embolization AND the documentation of embolization strategies in the presence of unilateral or bilateral absent uterine arteries", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "Society of Interventional Radiology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "interventionalRadiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_465_Registry.pdf" } }, { "title": "Developmental Screening in the First Three Years of Life", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1448", "measureId": "467", "description": "The percentage of children screened for risk of developmental, behavioral and social delays using a standardized screening tool in the 12 months preceding or on their first, second, or third birthday. This is a composite measure of screening in the first three years of life that includes three, age-specific indicators assessing whether children are screened in the 12 months proceeding or on their first, second or third birthday", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "primarySteward": "Oregon Health & Science University", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "overallAlgorithm": "overallStratumOnly", "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "pediatrics" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2018_Measure_467_Registry.pdf" }, "strata": [ { "name": "<1", "description": "Children in the eligible population who turned 1 during the performance period. (Birth to 1 year of age) who were screened for risk of developmental, behavioral and social delays using a standardized tool with interpretation and report within 12 months preceding or on their birthday" }, { "name": "1-2", "description": "Children in the eligible population who turned 2 during the performance period (> 1 year to 2 years of age) who were screened for risk of developmental, behavioral and social delays using a standardized tool with interpretation and report within 12 months preceding or on their birthday" }, { "name": "2-3", "description": "Children in the eligible population who turned 3 during the performance period ( > 2 years to 3 years of age) who were screened for risk of developmental, behavioral and social delays using a standardized tool with interpretation and report within 12 months preceding or on their birthday" }, { "name": "overall", "description": "Total Performance Rate based on all children who turned 1, 2, or 3 during the performance period who were screened for risk of developmental, behavioral and social delays using a standardized tool with interpretation and report within 12 months preceding or on their birthday, i.e., the sum of denominators 1, 2, and 3." } ] }, { "measureId": "PI_INFBLO_1", "category": "pi", "title": "Prevention of Information Blocking Attestation", "description": "I attest to CMS that I - (A) did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology. (B) Implemented technologies, standards, policies, practices, and agreements reasonably calculated to ensure, to the greatest extent practicable and permitted by law, that the certified EHR technology was, at all relevant times: (1) Connected in accordance with applicable law; (2) Compliant with all standards applicable to the exchange of information, including the standards, implementation specifications, and certification criteria adopted at 45 CFR part 170;  (3) Implemented in a manner that allowed for timely access by patients to their electronic health information; and (4) Implemented in a manner that allowed for the timely, secure, and trusted bi-directional exchange of structured electronic health information with other health care providers (as defined by 42 U.S.C. 300jj(3)), including unaffiliated health care providers, and with disparate certified EHR technology and vendors. (C) Responded in good faith and in a timely manner to requests to retrieve or exchange electronic health information, including from patients, health care providers (as defined by 42 U.S.C. 300jj(3)), and other persons, regardless of the requestor’s affiliation or technology vendor.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": 0, "isRequired": true, "isBonus": false, "measureSets": [], "objective": null, "reportingCategory": "attestation", "substitutes": [] }, { "measureId": "PI_ONCDIR_1", "category": "pi", "title": "ONC Direct Review Attestation", "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": 0, "isRequired": true, "isBonus": false, "measureSets": [], "objective": null, "reportingCategory": "attestation", "substitutes": [] }, { "measureId": "PI_ONCACB_1", "category": "pi", "title": "ONC-ACB Surveillance Attestation (Optional)", "description": "I have (1) Acknowledged the option to cooperate in good faith with ONC–ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC–ACB surveillance is received; and (2) If requested, cooperated in good faith with ONC–ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": 0, "isRequired": false, "isBonus": false, "measureSets": [], "objective": null, "reportingCategory": "attestation", "substitutes": [] }, { "measureId": "PI_IACEHRT_1", "category": "pi", "title": "PI bonus for submission of eligible Improvement Activities using CEHRT", "description": "I attest that I have submitted an eligible Improvement Activity using Certified Electronic Health Record Technology (CEHRT).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": 10, "isRequired": false, "isBonus": true, "measureSets": [], "objective": null, "reportingCategory": "cehrtBonus", "substitutes": [] }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "PI_LVPP_1", "title": "E-Prescribing Exclusion", "description": "A MIPS eligible clinician (EC) who writes fewer than 100 permissible prescriptions during the performance period is eligible for exclusion from the required e-prescribing measure.", "isRequired": false, "weight": 0, "measureSets": [], "isBonus": false, "objective": "electronicPrescribing", "reportingCategory": "base", "substitutes": [ "PI_EP_1", "PI_TRANS_EP_1", "PI_TRANS_LVPP_1" ] }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "PI_TRANS_LVPP_1", "title": "E-Prescribing Exclusion", "description": "A MIPS eligible clinician (EC) who writes fewer than 100 permissible prescriptions during the performance period is eligible for exclusion from the required e-prescribing measure.", "isRequired": false, "weight": 0, "measureSets": [ "transition" ], "isBonus": false, "objective": "electronicPrescribing", "reportingCategory": "base", "substitutes": [ "PI_TRANS_EP_1", "PI_LVPP_1", "PI_EP_1" ] }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "PI_LVOTC_1", "title": "Send a Summary of Care Exclusion", "description": "Any MIPS eligible clinician who transfers a patient to another setting or refers a patient less than 100 times during the performance period.", "isRequired": false, "weight": 0, "measureSets": [], "isBonus": false, "objective": "healthInformationExchange", "reportingCategory": "base", "substitutes": [ "PI_HIE_1", "PI_TRANS_HIE_1", "PI_TRANS_LVOTC_1" ] }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "PI_TRANS_LVOTC_1", "title": "Health Information Exchange Exclusion", "description": "Any MIPS eligible clinician who transfers a patient to another setting or refers a patient less than 100 times during the performance period.", "isRequired": false, "weight": 0, "measureSets": [ "transition" ], "isBonus": false, "objective": "healthInformationExchange", "reportingCategory": "base", "substitutes": [ "PI_TRANS_HIE_1", "PI_HIE_1", "PI_LVOTC_1", "PI_HIE_2", "PI_LVITC_1" ] }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "PI_LVITC_1", "title": "Request/Accept Summary of Care Exclusion", "description": "Any MIPS eligible clinician who does not receive any transitions of care or referrals or have patient encounters in which the MIPS eligible clinician has never before encountered the patient during the performance period.", "isRequired": false, "weight": 0, "measureSets": [], "isBonus": false, "objective": "healthInformationExchange", "reportingCategory": "base", "substitutes": [ "PI_HIE_2", "PI_TRANS_HIE_1", "PI_TRANS_LVOTC_1" ] }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "PI_PHCDRR_5", "title": "Clinical Data Registry Reporting", "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry. To earn a 5 % bonus in the promoting interoperability performance category score for submitting to one or more public health or clinical data registries also attest to PI_PHCDRR_5_MULTI.", "isRequired": false, "weight": 10, "measureSets": [], "isBonus": false, "objective": "publicHealthAndClinicalDataRegistryReporting", "reportingCategory": "registryBonus", "substitutes": [ "PI_TRANS_PHCDRR_3" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2018.MIPS ACI Measure_Clinical Data Registry Reporting.pdf" } }, { "category": "pi", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "PI_PHCDRR_5_MULTI", "title": "Clinical Data Registry Reporting for Multiple Registry Engagement", "description": "Report as true if,  active engagement with more than one Clinical Data Registry in accordance with PI_PHCDRR_5.", "isRequired": false, "weight": 5, "measureSets": [], "isBonus": true, "objective": "publicHealthAndClinicalDataRegistryReporting", "reportingCategory": "registryBonus", "substitutes": [ "PI_TRANS_PHCDRR_3_MULTI" ] }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "PI_HIE_3", "title": "Clinical Information Reconciliation", "description": "For at least one transition of care or referral received or patient encounter in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician performs clinical information reconciliation. The MIPS eligible clinician must implement clinical information reconciliation for the following three clinical information sets: (1) Medication. Review of the patient's medication, including the name, dosage, frequency, and route of each medication. (2) Medication allergy. Review of the patient's known medication allergies. (3) Current Problem list. Review of the patient's current and active diagnoses.", "isRequired": false, "weight": 10, "measureSets": [], "isBonus": false, "objective": "healthInformationExchange", "reportingCategory": "performanceBonus", "substitutes": [ "PI_TRANS_MR_1" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2018.MIPS ACI Measure_Clinical Information Reconciliation.pdf" } }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "PI_PHCDRR_3", "title": "Electronic Case Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions. To earn a 5 % bonus in the promoting interoperability performance category score for submitting to one or more public health or clinical data registries also attest to PI_PHCDRR_3_MULTI.", "isRequired": false, "weight": 10, "measureSets": [], "isBonus": false, "objective": "publicHealthAndClinicalDataRegistryReporting", "reportingCategory": "registryBonus", "substitutes": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2018.MIPS ACI Measure_Electronic Case Reporting.pdf" } }, { "category": "pi", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "PI_PHCDRR_3_MULTI", "title": "Electronic Case Reporting for Multiple Registry Engagement", "description": "Report as true if,  active engagement with more than one Electronic Case Reporting registry in accordance with PI_PHCDRR_3.", "isRequired": false, "weight": 5, "measureSets": [], "isBonus": true, "objective": "publicHealthAndClinicalDataRegistryReporting", "reportingCategory": "registryBonus", "substitutes": [] }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "PI_EP_1", "title": "e-Prescribing", "description": "At least one permissible prescription written by the MIPS eligible clinician is queried for a drug formulary and transmitted electronically using certified EHR technology.", "isRequired": true, "weight": 0, "measureSets": [], "isBonus": false, "objective": "electronicPrescribing", "reportingCategory": "base", "substitutes": [ "PI_LVPP_1", "PI_TRANS_EP_1", "PI_TRANS_LVPP_1" ], "exclusion": "PI_LVPP_1", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2018.MIPS ACI Measure_e-Prescribing.pdf" } }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", "isRequired": false, "weight": 10, "measureSets": [], "isBonus": false, "objective": "publicHealthAndClinicalDataRegistryReporting", "reportingCategory": "performanceBonus", "substitutes": [ "PI_TRANS_PHCDRR_1" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2018.MIPS ACI Measure_Immunization Registry Reporting.pdf" } }, { "category": "pi", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "PI_PHCDRR_1_MULTI", "title": "Immunization Registry Reporting for Multiple Registry Engagement", "description": "Report as true if active engagement with more than one immunization registry in accordance with PI_PHCDRR_1.", "isRequired": false, "weight": 5, "measureSets": [], "isBonus": true, "objective": "publicHealthAndClinicalDataRegistryReporting", "reportingCategory": "performanceBonus", "substitutes": [ "PI_TRANS_PHCDRR_1_MULTI" ] }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "PI_CCTPE_3", "title": "Patient-Generated Health Data", "description": "Patient-generated health data or data from a non-clinical setting is incorporated into the certified EHR technology for at least one unique patient seen by the MIPS eligible clinician during the performance period.", "isRequired": false, "weight": 10, "measureSets": [], "isBonus": false, "objective": "coordinationOfCareThroughPatientEngagement", "reportingCategory": "performanceBonus", "substitutes": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2018.MIPS ACI Measure_Patient-Generated Health Data.pdf" } }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "PI_PEA_2", "title": "Patient-Specific Education", "description": "The MIPS eligible clinician must use clinically relevant information from certified EHR technology to identify patient-specific educational resources and provide electronic access to those materials to at least one unique patient seen by the MIPS eligible clinician.", "isRequired": false, "weight": 10, "measureSets": [], "isBonus": false, "objective": "patientElectronicAccess", "reportingCategory": "performanceBonus", "substitutes": [ "PI_TRANS_PSE_1" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2018.MIPS ACI Measure_Patient-Specific Education.pdf" } }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "PI_PEA_1", "title": "Provide Patient Access", "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programing Interface (API) in the MIPS eligible clinician's certified EHR technology.", "isRequired": true, "weight": 10, "measureSets": [], "isBonus": false, "objective": "patientElectronicAccess", "reportingCategory": "base", "substitutes": [ "PI_TRANS_PEA_1" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2018.MIPS ACI Measure_Provide Patient Access.pdf" } }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "PI_PHCDRR_4", "title": "Public Health Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries. To earn a 5 % bonus in the promoting interoperability performance category score for submitting to one or more public health or clinical data registries also attest to PI_PHCDRR_4_MULTI.", "isRequired": false, "weight": 10, "measureSets": [], "isBonus": false, "objective": "publicHealthAndClinicalDataRegistryReporting", "reportingCategory": "registryBonus", "substitutes": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2018.MIPS ACI Measure_Public Health Registry Reporting.pdf" } }, { "category": "pi", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "PI_PHCDRR_4_MULTI", "title": "Public Health Registry Reporting for Multiple Registry Engagement", "description": "Report as true if,  active engagement with more than one Public Health Registry in accordance with PI_PHCDRR_4.", "isRequired": false, "weight": 5, "measureSets": [], "isBonus": true, "objective": "publicHealthAndClinicalDataRegistryReporting", "reportingCategory": "registryBonus", "substitutes": [] }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "PI_HIE_2", "title": "Request/Accept Summary of Care", "description": "For at least one transition of care or referral received or patient encounter in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician receives or retrieves and incorporates into the patient's record an electronic summary of care document.", "isRequired": true, "weight": 10, "measureSets": [], "isBonus": false, "objective": "healthInformationExchange", "reportingCategory": "base", "substitutes": [ "PI_LVITC_1", "PI_TRANS_HIE_1", "PI_TRANS_LVOTC_1" ], "exclusion": "PI_LVITC_1", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2018.MIPS ACI Measure_Request-Accept Summary of Care.pdf" } }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "PI_CCTPE_2", "title": "Secure Messaging", "description": "For at least one unique patient seen by the MIPS eligible clinician during the performance period, a secure message was sent using the electronic messaging function of certified EHR technology to the patient (or the patient-authorized representative), or in response to a secure message sent by the patient (or the patient-authorized representative).", "isRequired": false, "weight": 10, "measureSets": [], "isBonus": false, "objective": "coordinationOfCareThroughPatientEngagement", "reportingCategory": "performanceBonus", "substitutes": [ "PI_TRANS_SM_1" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2018.MIPS ACI Measure_Secure Messaging.pdf" } }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified EHR technology in accordance with requirements in 45 CFR164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", "isRequired": true, "weight": 0, "measureSets": [], "isBonus": false, "objective": "protectPatientHealthInformation", "reportingCategory": "base", "substitutes": [ "PI_TRANS_PPHI_1" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2018.MIPS ACI Measure_Security Risk Analysis.pdf" } }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "PI_HIE_1", "title": "Send a Summary of Care", "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider-(1) creates a summary of care record using certified EHR technology; and (2) electronically exchanges the summary of care record.", "isRequired": true, "weight": 10, "measureSets": [], "isBonus": false, "objective": "healthInformationExchange", "reportingCategory": "base", "substitutes": [ "PI_LVOTC_1", "PI_TRANS_HIE_1", "PI_TRANS_LVOTC_1" ], "exclusion": "PI_LVOTC_1", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2018.MIPS ACI Measure_Send a Summary of Care.pdf" } }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "PI_PHCDRR_2", "title": "Syndromic Surveillance Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from a urgent care ambulatory setting where the jurisdiction accepts syndromic data from such settings and the standards are clearly defined. To earn a 5 % bonus in the promoting interoperability performance category score for submitting to one or more public health or clinical data registries also attest to PI_PHCDRR_2_MULTI.", "isRequired": false, "weight": 10, "measureSets": [], "isBonus": false, "objective": "publicHealthAndClinicalDataRegistryReporting", "reportingCategory": "registryBonus", "substitutes": [ "PI_TRANS_PHCDRR_2" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2018.MIPS ACI Measure_Syndromic Surveillance Reporting.pdf" } }, { "category": "pi", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "PI_PHCDRR_2_MULTI", "title": "Syndromic Surveillance Reporting for Multiple Registry Engagement", "description": "Report as true if,  active engagement with more than one Syndromic Surveillance registry in accordance with PI_PHCDRR_2.", "isRequired": false, "weight": 5, "measureSets": [], "isBonus": true, "objective": "publicHealthAndClinicalDataRegistryReporting", "reportingCategory": "registryBonus", "substitutes": [ "PI_TRANS_PHCDRR_2_MULTI" ] }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "PI_CCTPE_1", "title": "View, Download and Transmit (VDT)", "description": "During the performance period, at least one unique patient (or patient-authorized representatives) seen by the MIPS eligible clinician actively engages with the EHR made accessible by the MIPS eligible clinician. An MIPS eligible clinician may meet the measure by either-(1) view, download or transmit to a third party their health information; or (2) access their health information through the use of an API that can be used by applications chosen by the patient and configured to the API in the MIPS eligible clinician's certified EHR technology; or (3) a combination of (1) and (2).", "isRequired": false, "weight": 10, "measureSets": [], "isBonus": false, "objective": "coordinationOfCareThroughPatientEngagement", "reportingCategory": "performanceBonus", "substitutes": [ "PI_TRANS_PEA_2" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2018.MIPS ACI Measure_View Download or Transmit (VDT).pdf" } }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "PI_TRANS_EP_1", "title": "e-Prescribing", "description": "At least one permissible prescription written by the MIPS eligible clinician is queried for a drug formulary and transmitted electronically using certified EHR technology.", "isRequired": true, "weight": 0, "measureSets": [ "transition" ], "isBonus": false, "objective": "electronicPrescribing", "reportingCategory": "base", "substitutes": [ "PI_TRANS_LVPP_1", "PI_LVPP_1", "PI_EP_1" ], "exclusion": "PI_TRANS_LVPP_1", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Transition Measure Specifications/2018.MIPS ACI Transition Measure_e-Prescribing.pdf" } }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "PI_TRANS_HIE_1", "title": "Health Information Exchange", "description": "The MIPS eligible clinician that transitions or refers their patient to another setting of care or health care clinician (1) uses CEHRT to create a summary of care record; and (2) electronically transmits such summary to a receiving health care clinician for at least one transition of care or referral.", "isRequired": true, "weight": 20, "measureSets": [ "transition" ], "isBonus": false, "objective": "healthInformationExchange", "reportingCategory": "base", "substitutes": [ "PI_TRANS_LVOTC_1", "PI_HIE_1", "PI_LVOTC_1", "PI_HIE_2", "PI_LVITC_1" ], "exclusion": "PI_TRANS_LVOTC_1", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Transition Measure Specifications/2018.MIPS ACI Transition Measure_Health Information Exchange.pdf" } }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "PI_TRANS_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data.", "isRequired": false, "weight": 10, "measureSets": [ "transition" ], "isBonus": false, "objective": "publicHealthReporting", "reportingCategory": "performanceBonus", "substitutes": [ "PI_PHCDRR_1" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Transition Measure Specifications/2018.MIPS ACI Transition Measure_Immunization Registry Reporting.pdf" } }, { "category": "pi", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "PI_TRANS_PHCDRR_1_MULTI", "title": "Immunization Registry Reporting for Multiple Registry Engagement", "description": "Report as true if active engagement with more than one Immunization Registry in accordance with PI_TRANS_PHCDRR_1.", "isRequired": false, "weight": 5, "measureSets": [ "transition" ], "isBonus": true, "objective": "publicHealthReporting", "reportingCategory": "performanceBonus", "substitutes": [ "PI_PHCDRR_1_MULTI" ] }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "PI_TRANS_MR_1", "title": "Medication Reconciliation", "description": "The MIPS eligible clinician performs medication reconciliation for at least one transition of care in which the patient is transitioned into the care of the MIPS eligible clinician.", "isRequired": false, "weight": 10, "measureSets": [ "transition" ], "isBonus": false, "objective": "medicationReconciliation", "reportingCategory": "performanceBonus", "substitutes": [ "PI_HIE_3" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Transition Measure Specifications/2018.MIPS ACI Transition Measure_Medication Reconciliation.pdf" } }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "PI_TRANS_PSE_1", "title": "Patient-Specific Education", "description": "The MIPS eligible clinician must use clinically relevant information from CEHRT to identify patient-specific educational resources and provide access to those materials to at least one unique patient seen by the MIPS eligible clinician.", "isRequired": false, "weight": 10, "measureSets": [ "transition" ], "isBonus": false, "objective": "patientSpecificEducation", "reportingCategory": "performanceBonus", "substitutes": [ "PI_PEA_2" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Transition Measure Specifications/2018.MIPS ACI Transition Measure_Patient Specific Education.pdf" } }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "PI_TRANS_PEA_1", "title": "Provide Patient Access", "description": "At least one patient seen by the MIPS eligible clinician during the performance period is provided timely access to view online, download, and transmit to a third party their health information subject to the MIPS eligible clinician's discretion to withhold certain information.", "isRequired": true, "weight": 20, "measureSets": [ "transition" ], "isBonus": false, "objective": "patientElectronicAccess", "reportingCategory": "base", "substitutes": [ "PI_PEA_1" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Transition Measure Specifications/2018.MIPS ACI Transition Measure_Provide Patient Access.pdf" } }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "PI_TRANS_SM_1", "title": "Secure Messaging", "description": "For at least one unique patient seen by the MIPS eligible clinician during the performance period, a secure message was sent using the electronic messaging function of CEHRT to the patient (or the patient-authorized representative), or in response to a secure message sent by the patient (or the patient-authorized representative) during the performance period.", "isRequired": false, "weight": 10, "measureSets": [ "transition" ], "isBonus": false, "objective": "secureMessaging", "reportingCategory": "performanceBonus", "substitutes": [ "PI_CCTPE_2" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Transition Measure Specifications/2018.MIPS ACI Transition Measure_Secure Messaging.pdf" } }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "PI_TRANS_PPHI_1", "title": "Security Risk Analysis", "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified EHR technology in accordance with requirements in 45 CFR164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", "isRequired": true, "weight": 0, "measureSets": [ "transition" ], "isBonus": false, "objective": "protectPatientHealthInformation", "reportingCategory": "base", "substitutes": [ "PI_PPHI_1" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Transition Measure Specifications/2018.MIPS ACI Transition Measure_Security Risk Analysis.pdf" } }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "PI_TRANS_PHCDRR_3", "title": "Specialized Registry Reporting", "description": "The MIPS eligible clinician is in active engagement to submit data to specialized registry. To earn a 5 % bonus in the promoting interoperability performance category score for submitting to one or more public health or clinical data registries also attest to PI_TRANS_PHCDRR_3_MULTI.", "isRequired": false, "weight": 10, "measureSets": [ "transition" ], "isBonus": false, "objective": "publicHealthReporting", "reportingCategory": "registryBonus", "substitutes": [ "PI_PHCDRR_5" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Transition Measure Specifications/2018.MIPS ACI Transition Measure_Specialized Registry Reporting.pdf" } }, { "category": "pi", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "PI_TRANS_PHCDRR_3_MULTI", "title": "Specialized Registry Reporting for Multiple Registry Engagement", "description": "Report as true if active engagement with more than one Specialized Registry in accordance with PI_TRANS_PHCDRR_3.", "isRequired": false, "weight": 5, "measureSets": [ "transition" ], "isBonus": true, "objective": "publicHealthReporting", "reportingCategory": "registryBonus", "substitutes": [ "PI_PHCDRR_5_MULTI" ] }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "PI_TRANS_PHCDRR_2", "title": "Syndromic Surveillance Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data. To earn a 5 % bonus in the promoting interoperability performance category score for submitting to one or more public health or clinical data registries also attest to PI_TRANS_PHCDRR_2_MULTI.", "isRequired": false, "weight": 10, "measureSets": [ "transition" ], "isBonus": false, "objective": "publicHealthReporting", "reportingCategory": "registryBonus", "substitutes": [ "PI_PHCDRR_2" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Transition Measure Specifications/2018.MIPS ACI Transition Measure_Syndromic Surveillance Reporting.pdf" } }, { "category": "pi", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "PI_TRANS_PHCDRR_2_MULTI", "title": "Syndromic Surveillance Reporting for Multiple Registry Engagement", "description": "Report as true if active engagement with more than one Syndromic Surveillance Registry in accordance with PI_TRANS_PHCDRR_2.", "isRequired": false, "weight": 5, "measureSets": [ "transition" ], "isBonus": true, "objective": "publicHealthReporting", "reportingCategory": "registryBonus", "substitutes": [ "PI_PHCDRR_2_MULTI" ] }, { "category": "pi", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "PI_TRANS_PEA_2", "title": "View, Download, or Transmit (VDT)", "description": "At least one patient seen by the MIPS eligible clinician during the performance period (or patient-authorized representative) views, downloads or transmits their health information to a third party during the performance period.", "isRequired": false, "weight": 10, "measureSets": [ "transition" ], "isBonus": false, "objective": "patientElectronicAccess", "reportingCategory": "performanceBonus", "substitutes": [ "PI_CCTPE_1" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Transition Measure Specifications/2018.MIPS ACI Transition Measure_View Download or Transmit (VDT).pdf" } }, { "title": "Engagement of New Medicaid Patients and Follow-up", "category": "ia", "description": "Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare. A timely manner is defined as within 10 business days for this activity.", "measureId": "IA_AHE_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "achievingHealthEquity", "cehrtEligible": false }, { "title": "Leveraging a QCDR to standardize processes for screening", "category": "ia", "description": "Participation in a QCDR, demonstrating performance of activities for use of standardized processes for screening for social determinants of health such as food security, employment and housing. Use of supporting tools that can be incorporated into the certified EHR technology is also suggested.", "measureId": "IA_AHE_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "achievingHealthEquity", "cehrtEligible": true }, { "title": "Promote Use of Patient-Reported Outcome Tools", "category": "ia", "description": "Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PQH-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.", "measureId": "IA_AHE_3", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "achievingHealthEquity", "cehrtEligible": true }, { "title": "Leveraging a QCDR for use of standard questionnaires", "category": "ia", "description": "Participation in a QCDR, demonstrating performance of activities for use of standard questionnaires for assessing improvements in health disparities related to functional health status (e.g., use of Seattle Angina Questionnaire, MD Anderson Symptom Inventory, and/or SF-12/VR-12 functional health status assessment).", "measureId": "IA_AHE_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "achievingHealthEquity", "cehrtEligible": false }, { "title": "MIPS Eligible Clinician Leadership in Clinical Trials or CBPR", "category": "ia", "description": "MIPS eligible clinician leadership in clinical trials, research alliances or community-based participatory research (CBPR) that identify tools, research or processes that can focuses on minimizing disparities in healthcare access, care quality, affordability, or outcomes.", "measureId": "IA_AHE_5", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "achievingHealthEquity", "cehrtEligible": false }, { "title": "Provide Education Opportunities for New Clinicians", "category": "ia", "description": "MIPS eligible clinicians acting as a preceptor for clinicians-in-training (such as medical residents/fellows, medical students, physician assistants, nurse practitioners, or clinical nurse specialists) and accepting such clinicians for clinical rotations in community practices in small, underserved, or rural areas.", "measureId": "IA_AHE_6", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "achievingHealthEquity", "cehrtEligible": false }, { "title": "Use of certified EHR to capture patient reported outcomes", "category": "ia", "description": "In support of improving patient access, performing additional activities that enable capture of patient reported outcomes (e.g., home blood pressure, blood glucose logs, food diaries, at-risk health factors such as tobacco or alcohol use, etc.) or patient activation measures through use of certified EHR technology, containing this data in a separate queue for clinician recognition and review.", "measureId": "IA_BE_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "cehrtEligible": true }, { "title": "Participation in a QCDR, that promotes implementation of patient self-action plans.", "category": "ia", "description": "Participation in a QCDR, that promotes implementation of patient self-action plans.", "measureId": "IA_BE_10", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "cehrtEligible": false }, { "title": "Participation in a QCDR, that promotes use of processes and tools that engage patients for adherence to treatment plan.", "category": "ia", "description": "Participation in a QCDR, that promotes use of processes and tools that engage patients for adherence to treatment plan.", "measureId": "IA_BE_11", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "cehrtEligible": false }, { "title": "Use evidence-based decision aids to support shared decision-making.", "category": "ia", "description": "Use evidence-based decision aids to support shared decision-making.", "measureId": "IA_BE_12", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "cehrtEligible": false }, { "title": "Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.", "category": "ia", "description": "Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.", "measureId": "IA_BE_13", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "cehrtEligible": false }, { "title": "Engage Patients and Families to Guide Improvement in the System of Care", "category": "ia", "description": "Engage patients and families to guide improvement in the system of care by leveraging digital tools for ongoing guidance and assessments outside the encounter, including the collection and use of patient data for return-to-work and patient quality of life improvement. Platforms and devices that collect patient-generated health data (PGHD) must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient, including patient reported outcomes (PROs). Examples include patient engagement and outcomes tracking platforms, cellular or web-enabled bi-directional systems, and other devices that transmit clinically valid objective and subjective data back to care teams. Because many consumer-grade devices capture PGHD (for example, wellness devices), platforms or devices eligible for this improvement activity must be, at a minimum, endorsed and offered clinically by care teams to patients to automatically send ongoing guidance (one way). Platforms and devices that additionally collect PGHD must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient (e.g. automated patient-facing instructions based on glucometer readings). Therefore, unlike passive platforms or devices that may collect but do not transmit PGHD in real or near-real time to clinical care teams, active devices and platforms can inform the patient or the clinical care team in a timely manner of important parameters regarding a patient’s status, adherence, comprehension, and indicators of clinical concern.", "measureId": "IA_BE_14", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "beneficiaryEngagement", "cehrtEligible": true }, { "title": "Engagement of Patients, Family, and Caregivers in Developing a Plan of Care", "category": "ia", "description": "Engage patients, family, and caregivers in developing a plan of care and prioritizing their goals for action, documented in the electronic health record (EHR) technology.", "measureId": "IA_BE_15", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "cehrtEligible": true }, { "title": "Evidenced-based techniques to promote self-management into usual care", "category": "ia", "description": "Incorporate evidence-based techniques to promote self-management into usual care, using techniques such as goal setting with structured follow-up, Teach Back, action planning or motivational interviewing.", "measureId": "IA_BE_16", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "cehrtEligible": false }, { "title": "Use of tools to assist patient self-management", "category": "ia", "description": "Use tools to assist patients in assessing their need for support for self-management (e.g., the Patient Activation Measure or How’s My Health).", "measureId": "IA_BE_17", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "cehrtEligible": false }, { "title": "Provide peer-led support for self-management.", "category": "ia", "description": "Provide peer-led support for self-management.", "measureId": "IA_BE_18", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "cehrtEligible": false }, { "title": "Use group visits for common chronic conditions (e.g., diabetes).", "category": "ia", "description": "Use group visits for common chronic conditions (e.g., diabetes).", "measureId": "IA_BE_19", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "cehrtEligible": false }, { "title": "Use of QCDR to support clinical decision making", "category": "ia", "description": "Participation in a QCDR, demonstrating performance of activities that promote implementation of shared clinical decision making capabilities.", "measureId": "IA_BE_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "cehrtEligible": false }, { "title": "Implementation of condition-specific chronic disease self-management support programs", "category": "ia", "description": "Provide condition-specific chronic disease self-management support programs or coaching or link patients to those programs in the community.", "measureId": "IA_BE_20", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "cehrtEligible": false }, { "title": "Improved Practices that Disseminate Appropriate Self-Management Materials", "category": "ia", "description": "Provide self-management materials at an appropriate literacy level and in an appropriate language.", "measureId": "IA_BE_21", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "cehrtEligible": false }, { "title": "Improved Practices that Engage Patients Pre-Visit", "category": "ia", "description": "Implementation of workflow changes that engage patients prior to the visit, such as a pre-visit development of a shared visit agenda with the patient, or targeted pre-visit laboratory testing that will be resulted and available to the MIPS eligible clinician to review and discuss during the patient’s appointment..", "measureId": "IA_BE_22", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "cehrtEligible": false }, { "title": "Integration of patient coaching practices between visits", "category": "ia", "description": "Provide coaching between visits with follow-up on care plan and goals.", "measureId": "IA_BE_23", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "cehrtEligible": false }, { "title": "Engagement with QIN-QIO to implement self-management training programs", "category": "ia", "description": "Engagement with a Quality Innovation Network-Quality Improvement Organization, which may include participation in self-management training programs such as diabetes.", "measureId": "IA_BE_3", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "cehrtEligible": false }, { "title": "Engagement of patients through implementation of improvements in patient portal", "category": "ia", "description": "Access to an enhanced patient portal that provides up to date information related to relevant chronic disease health or blood pressure control, and includes interactive features allowing patients to enter health information and/or enables bidirectional communication about medication changes and adherence.", "measureId": "IA_BE_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "cehrtEligible": true }, { "title": "Enhancements/regular updates to practice websites/tools that also include considerations for patients with cognitive disabilities", "category": "ia", "description": "Enhancements and ongoing regular updates and use of websites/tools that include consideration for compliance with section 508 of the Rehabilitation Act of 1973 or for improved design for patients with cognitive disabilities. Refer to the CMS website on Section 508 of the Rehabilitation Act https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/Section508/index.html?redirect=/InfoTechGenInfo/07_Section508.asp that requires that institutions receiving federal funds solicit, procure, maintain and use all electronic and information technology (EIT) so that equal or alternate/comparable access is given to members of the public with and without disabilities. For example, this includes designing a patient portal or website that is compliant with section 508 of the Rehabilitation Act of 1973", "measureId": "IA_BE_5", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "cehrtEligible": false }, { "title": "Collection and follow-up on patient experience and satisfaction data on beneficiary engagement", "category": "ia", "description": "Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of improvement plan.", "measureId": "IA_BE_6", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "beneficiaryEngagement", "cehrtEligible": false }, { "title": "Participation in a QCDR, that promotes use of patient engagement tools.", "category": "ia", "description": "Participation in a QCDR, that promotes use of patient engagement tools.", "measureId": "IA_BE_7", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "cehrtEligible": false }, { "title": "Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive.", "category": "ia", "description": "Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive.", "measureId": "IA_BE_8", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "cehrtEligible": false }, { "title": "Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement.", "category": "ia", "description": "Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement.", "measureId": "IA_BE_9", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "cehrtEligible": false }, { "title": "Diabetes screening", "category": "ia", "description": "Diabetes screening for people with schizophrenia or bipolar disease who are using antipsychotic medication.", "measureId": "IA_BMH_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "behavioralAndMentalHealth", "cehrtEligible": false }, { "title": "Tobacco use", "category": "ia", "description": "Tobacco use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including tobacco use screening and cessation interventions (refer to NQF #0028) for patients with co-occurring conditions of behavioral or mental health and at risk factors for tobacco dependence.", "measureId": "IA_BMH_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "behavioralAndMentalHealth", "cehrtEligible": false }, { "title": "Unhealthy alcohol use", "category": "ia", "description": "Unhealthy alcohol use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including screening and brief counseling (refer to NQF #2152) for patients with co-occurring conditions of behavioral or mental health conditions.", "measureId": "IA_BMH_3", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "behavioralAndMentalHealth", "cehrtEligible": false }, { "title": "Depression screening", "category": "ia", "description": "Depression screening and follow-up plan: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including depression screening and follow-up plan (refer to NQF #0418) for patients with co-occurring conditions of behavioral or mental health conditions.", "measureId": "IA_BMH_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "behavioralAndMentalHealth", "cehrtEligible": false }, { "title": "MDD prevention and treatment interventions", "category": "ia", "description": "Major depressive disorder: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including suicide risk assessment (refer to NQF #0104) for mental health patients with co-occurring conditions of behavioral or mental health conditions.", "measureId": "IA_BMH_5", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "behavioralAndMentalHealth", "cehrtEligible": false }, { "title": "Implementation of co-location PCP and MH services", "category": "ia", "description": "Integration facilitation and promotion of the colocation of mental health and substance use disorder services in primary and/or non-primary clinical care settings.", "measureId": "IA_BMH_6", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "behavioralAndMentalHealth", "cehrtEligible": false }, { "title": "Implementation of Integrated Patient Centered Behavioral Health Model", "category": "ia", "description": "Offer integrated behavioral health services to support patients with behavioral health needs who also have conditions such as dementia or other poorly controlled chronic illnesses. The services could include one or more of the following: \n• Use evidence-based treatment protocols and treatment to goal where appropriate;\n• Use evidence-based screening and case finding strategies to identify individuals at risk and in need of services;\n• Ensure regular communication and coordinated workflows between MIPS eligible clinicians in primary care and behavioral health;\n• Conduct regular case reviews for at-risk or unstable patients and those who are not responding to treatment;\n• Use of a registry or health information technology functionality to support active care management and outreach to patients in treatment;\n• Integrate behavioral health and medical care plans and facilitate integration through co-location of services when feasible; and/or\n• Participate in the National Partnership to Improve Dementia Care Initiative, which promotes a multidimensional approach that includes public reporting, state-based coalitions, research, training, and revised surveyor guidance.", "measureId": "IA_BMH_7", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "behavioralAndMentalHealth", "cehrtEligible": true }, { "title": "Electronic Health Record Enhancements for BH data capture", "category": "ia", "description": "Enhancements to an electronic health record to capture additional data on behavioral health (BH) populations and use that data for additional decision-making purposes (e.g., capture of additional BH data results in additional depression screening for at-risk patient not previously identified).", "measureId": "IA_BMH_8", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "behavioralAndMentalHealth", "cehrtEligible": true }, { "title": "Unhealthy Alcohol Use for Patients with Co-occurring Conditions of Mental Health and Substance Abuse and Ambulatory Care Patients", "category": "ia", "description": "Individual MIPS eligible clinicians or groups must regularly engage in integrated prevention and treatment interventions, including screening and brief counseling (for example: NQF #2152) for patients with co-occurring conditions of mental health and substance abuse. MIPS eligible clinicians would attest that 60 percent for the CY 2018 Quality Payment Program performance period, and 75 percent beginning in the 2019 performance period, of their ambulatory care patients are screened for unhealthy alcohol use.", "measureId": "IA_BMH_9", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "behavioralAndMentalHealth", "cehrtEligible": false }, { "title": "Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop", "category": "ia", "description": "Performance of regular practices that include providing specialist reports back to the referring individual MIPS eligible clinician or group to close the referral loop or where the referring individual MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the EHR technology.", "measureId": "IA_CC_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "cehrtEligible": true }, { "title": "Care transition documentation practice improvements", "category": "ia", "description": "Implementation of practices/processes for care transition that include documentation of how a MIPS eligible clinician or group carried out a patient-centered action plan for first 30 days following a discharge (e.g., staff involved, phone calls conducted in support of transition, accompaniments, navigation actions, home visits, patient information access, etc.).", "measureId": "IA_CC_10", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "cehrtEligible": false }, { "title": "Care transition standard operational improvements", "category": "ia", "description": "Establish standard operations to manage transitions of care that could include one or more of the following: \n\nEstablish formalized lines of communication with local settings in which empaneled patients receive care to ensure documented flow of information and seamless transitions in care; and/or\n\nPartner with community or hospital-based transitional care services.", "measureId": "IA_CC_11", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "cehrtEligible": false }, { "title": "Care coordination agreements that promote improvements in patient tracking across settings", "category": "ia", "description": "Establish effective care coordination and active referral management that could include one or more of the following:\n\nEstablish care coordination agreements with frequently used consultants that set expectations for documented flow of information and MIPS eligible clinician or MIPS eligible clinician group expectations between settings. Provide patients with information that sets their expectations consistently with the care coordination agreements; \n\nTrack patients referred to specialist through the entire process; and/or\nSystematically integrate information from referrals into the plan of care.", "measureId": "IA_CC_12", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "cehrtEligible": false }, { "title": "Practice Improvements for Bilateral Exchange of Patient Information", "category": "ia", "description": "Ensure that there is bilateral exchange of necessary patient information to guide patient care, such as Open Notes, that could include one or more of the following: \n• Participate in a Health Information Exchange if available; and/or \n• Use structured referral notes.", "measureId": "IA_CC_13", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "cehrtEligible": true }, { "title": "Practice Improvements that Engage Community Resources to Support Patient Health Goals", "category": "ia", "description": "Develop pathways to neighborhood/community-based resources to support patient health goals that could include one or more of the following: \n• Maintain formal (referral) links to community-based chronic disease self-management support programs, exercise programs and other wellness resources with the potential for bidirectional flow of information; and provide a guide to available community resources.\n• Including through the use of tools that facilitate electronic communication between settings;\n• Screen patients for health-harming legal needs;\n• Screen and assess patients for social needs using tools that are preferably health IT enabled and that include to any extent standards-based, coded question/field for the capture of data as is feasible and available as part of such tool; and/or\n• Provide a guide to available community resources.", "measureId": "IA_CC_14", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "cehrtEligible": true }, { "title": "PSH Care Coordination", "category": "ia", "description": "Participation in a Perioperative Surgical Home (PSH) that provides a patient-centered, physician-led, interdisciplinary, and team-based system of coordinated patient care, which coordinates care from pre-procedure assessment through the acute care episode, recovery, and post-acute care. This activity allows for reporting of strategies and processes related to care coordination of patients receiving surgical or procedural care within a PSH. The clinician must perform one or more of the following care coordination activities:\n• Coordinate with care managers/navigators in preoperative clinic to plan and implementation comprehensive post discharge plan of care;\n• Deploy perioperative clinic and care processes to reduce post-operative visits to emergency rooms;\n• Implement evidence-informed practices and standardize care across the entire spectrum of surgical patients; or\n• Implement processes to ensure effective communications and education of patients’ post-discharge instructions.", "measureId": "IA_CC_15", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "cehrtEligible": true }, { "title": "Primary Care Physician and Behavioral Health Bilateral Electronic Exchange of Information for Shared Patients", "category": "ia", "description": "The primary care and behavioral health practices use the same electronic health record system for shared patients or have an established bidirectional flow of primary care and behavioral health records.", "measureId": "IA_CC_16", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "cehrtEligible": true }, { "title": "Patient Navigator Program", "category": "ia", "description": "Implement a Patient Navigator Program that offers evidence-based resources and tools to reduce avoidable hospital readmissions, utilizing a patient-centered and team-based approach, leveraging evidence-based best practices to improve care for patients by making hospitalizations less stressful, and the recovery period more supportive by implementing quality improvement strategies.", "measureId": "IA_CC_17", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "careCoordination", "cehrtEligible": false }, { "title": "Implementation of improvements that contribute to more timely communication of test results", "category": "ia", "description": "Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.", "measureId": "IA_CC_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "cehrtEligible": false }, { "title": "Implementation of additional activity as a result of TA for improving care coordination", "category": "ia", "description": "Implementation of at least one additional recommended activity from the Quality Innovation Network-Quality Improvement Organization after technical assistance has been provided related to improving care coordination.", "measureId": "IA_CC_3", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "cehrtEligible": false }, { "title": "TCPI Participation", "category": "ia", "description": "Participation in the CMS Transforming Clinical Practice Initiative", "measureId": "IA_CC_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "cehrtEligible": false }, { "title": "CMS partner in Patients Hospital Engagement Network", "category": "ia", "description": "Membership and participation in a CMS Partnership for Patients Hospital Engagement Network.", "measureId": "IA_CC_5", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "cehrtEligible": false }, { "title": "Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination", "category": "ia", "description": "Participation in a Qualified Clinical Data Registry, demonstrating performance of activities that promote use of standard practices, tools and processes for quality improvement (e.g., documented preventative screening and vaccinations that can be shared across MIPS eligible clinician or groups).", "measureId": "IA_CC_6", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "cehrtEligible": false }, { "title": "Regular training in care coordination", "category": "ia", "description": "Implementation of regular care coordination training.", "measureId": "IA_CC_7", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "cehrtEligible": false }, { "title": "Implementation of documentation improvements for practice/process improvements", "category": "ia", "description": "Implementation of practices/processes that document care coordination activities (e.g., a documented care coordination encounter that tracks all clinical staff involved and communications from date patient is scheduled for outpatient procedure through day of procedure).", "measureId": "IA_CC_8", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "cehrtEligible": true }, { "title": "Implementation of practices/processes for developing regular individual care plans", "category": "ia", "description": "Implementation of practices/processes, including a discussion on care, to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s). Individual care plans should include consideration of a patient’s goals and priorities, as well as desired outcomes of care.", "measureId": "IA_CC_9", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "cehrtEligible": true }, { "title": "Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record", "category": "ia", "description": "• Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent and emergent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:\n• Expanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);\n• Use of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or\nProvision of same-day or next-day access to a consistent MIPS eligible clinician, group or care team when needed for urgent care or transition management.", "measureId": "IA_EPA_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "expandedPracticeAccess", "cehrtEligible": true }, { "title": "Use of telehealth services that expand practice access", "category": "ia", "description": "Use of telehealth services and analysis of data for quality improvement, such as participation in remote specialty care consults or teleaudiology pilots that assess ability to still deliver quality care to patients.", "measureId": "IA_EPA_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "expandedPracticeAccess", "cehrtEligible": false }, { "title": "Collection and use of patient experience and satisfaction data on access", "category": "ia", "description": "Collection of patient experience and satisfaction data on access to care and development of an improvement plan, such as outlining steps for improving communications with patients to help understanding of urgent access needs.", "measureId": "IA_EPA_3", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "expandedPracticeAccess", "cehrtEligible": false }, { "title": "Additional improvements in access as a result of QIN/QIO TA", "category": "ia", "description": "As a result of Quality Innovation Network-Quality Improvement Organization technical assistance, performance of additional activities that improve access to services (e.g., investment of on-site diabetes educator).", "measureId": "IA_EPA_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "expandedPracticeAccess", "cehrtEligible": false }, { "title": "Participation in User Testing of the Quality Payment Program Website (https://qpp.cms.gov/)", "category": "ia", "description": "User participation in the Quality Payment Program website testing is an activity for eligible clinicians who have worked with CMS to provided substantive, timely, and responsive input to improve the CMS Quality Payment Program website through product user-testing that enhances system and program accessibility, readability and responsiveness as well as providing feedback for developing tools and guidance thereby allowing for a more user-friendly and accessible clinician and practice Quality Payment Program website experience.", "measureId": "IA_EPA_5", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "expandedPracticeAccess", "cehrtEligible": false }, { "title": "Participation on Disaster Medical Assistance Team, registered for 6 months.", "category": "ia", "description": "Participation in Disaster Medical Assistance Teams, or Community Emergency Responder Teams. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and MIPS eligible clinician groups must be registered for a minimum of 6 months as a volunteer for disaster or emergency response.", "measureId": "IA_ERP_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "emergencyResponseAndPreparedness", "cehrtEligible": false }, { "title": "Participation in a 60-day or greater effort to support domestic or international humanitarian needs.", "category": "ia", "description": "Participation in domestic or international humanitarian volunteer work. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and groups attest to domestic or international humanitarian volunteer work for a period of a continuous 60 days or greater.", "measureId": "IA_ERP_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "emergencyResponseAndPreparedness", "cehrtEligible": false }, { "title": "Electronic submission of Patient Centered Medical Home accreditation", "category": "ia", "description": "N/A", "measureId": "IA_PCMH", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": null, "subcategoryId": null, "cehrtEligible": false }, { "title": "Participation in Systematic Anticoagulation Program", "category": "ia", "description": "Participation in a systematic anticoagulation program (coagulation clinic, patient self-reporting program, or patient self-management program) for 60 percent of practice patients in the transition year and 75 percent of practice patients in Quality Payment Program Year 2 and future years, who receive anti-coagulation medications (warfarin or other coagulation cascade inhibitors).", "measureId": "IA_PM_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "populationManagement", "cehrtEligible": false }, { "title": "Use of QCDR data for quality improvement such as comparative analysis reports across patient populations", "category": "ia", "description": "Participation in a QCDR, clinical data registries, or other registries run by other government agencies such as FDA, or private entities such as a hospital or medical or surgical society. Activity must include use of QCDR data for quality improvement (e.g., comparative analysis across specific patient populations for adverse outcomes after an outpatient surgical procedure and corrective steps to address adverse outcome).", "measureId": "IA_PM_10", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "cehrtEligible": false }, { "title": "Regular Review Practices in Place on Targeted Patient Population Needs", "category": "ia", "description": "Implementation of regular reviews of targeted patient population needs, such as structured clinical case reviews, which includes access to reports that show unique characteristics of eligible clinician's patient population, identification of vulnerable patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources.", "measureId": "IA_PM_11", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "cehrtEligible": false }, { "title": "Population empanelment", "category": "ia", "description": "Empanel (assign responsibility for) the total population, linking each patient to a MIPS eligible clinician or group or care team.\nEmpanelment is a series of processes that assign each active patient to a MIPS eligible clinician or group and/or care team, confirm assignment with patients and clinicians, and use the resultant patient panels as a foundation for individual patient and population health management. \nEmpanelment identifies the patients and population for whom the MIPS eligible clinician or group and/or care team is responsible and is the foundation for the relationship continuity between patient and MIPS eligible clinician or group /care team that is at the heart of comprehensive primary care. Effective empanelment requires identification of the “active population” of the practice: those patients who identify and use your practice as a source for primary care. There are many ways to define “active patients” operationally, but generally, the definition of “active patients” includes patients who have sought care within the last 24 to 36 months, allowing inclusion of younger patients who have minimal acute or preventive health care.", "measureId": "IA_PM_12", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "cehrtEligible": false }, { "title": "Chronic Care and Preventative Care Management for Empaneled Patients", "category": "ia", "description": "Proactively manage chronic and preventive care for empaneled patients that could include one or more of the following: \n• Provide patients annually with an opportunity for development and/or adjustment of an individualized plan of care as appropriate to age and health status, including health risk appraisal; gender, age and condition-specific preventive care services; and plan of care for chronic conditions; \n• Use condition-specific pathways for care of chronic conditions (e.g., hypertension, diabetes, depression, asthma and heart failure) with evidence-based protocols to guide treatment to target; such as a CDC-recognized diabetes prevention program;\n• Use pre-visit planning to optimize preventive care and team management of patients with chronic conditions; \n• Use panel support tools (registry functionality) to identify services due;\n• Use predictive analytical models to predict risk, onset and progression of chronic diseases; or\n• Use reminders and outreach (e.g., phone calls, emails, postcards, patient portals and community health workers where available) to alert and educate patients about services due; and/or routine medication reconciliation.", "measureId": "IA_PM_13", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "cehrtEligible": true }, { "title": "Implementation of methodologies for improvements in longitudinal care management for high risk patients", "category": "ia", "description": "Provide longitudinal care management to patients at high risk for adverse health outcome or harm that could include one or more of the following: \nUse a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts. Monitor the risk-stratification method and refine as necessary to improve accuracy of risk status identification; \nUse a personalized plan of care for patients at high risk for adverse health outcome or harm, integrating patient goals, values and priorities; and/or\nUse on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients.", "measureId": "IA_PM_14", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "cehrtEligible": true }, { "title": "Implementation of episodic care management practice improvements", "category": "ia", "description": "Provide episodic care management, including management across transitions and referrals that could include one or more of the following:\nRoutine and timely follow-up to hospitalizations, ED visits and stays in other institutional settings, including symptom and disease management, and medication reconciliation and management; and/or\nManaging care intensively through new diagnoses, injuries and exacerbations of illness.", "measureId": "IA_PM_15", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "cehrtEligible": true }, { "title": "Implementation of medication management practice improvements", "category": "ia", "description": "Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: \nReconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; \nIntegrate a pharmacist into the care team; and/or\nConduct periodic, structured medication reviews.", "measureId": "IA_PM_16", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "cehrtEligible": true }, { "title": "Participation in Population Health Research", "category": "ia", "description": "Participation in federally and/or privately funded research that identifies interventions, tools, or processes that can improve a targeted patient population.", "measureId": "IA_PM_17", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "cehrtEligible": false }, { "title": "Provide Clinical-Community Linkages", "category": "ia", "description": "Engaging community health workers to provide a comprehensive link to community resources through family-based services focusing on success in health, education, and self-sufficiency. This activity supports individual MIPS eligible clinicians or groups that coordinate with primary care and other clinicians, engage and support patients, use of health information technology, and employ quality measurement and improvement processes. An example of this community based program is the NCQA Patient-Centered Connected Care (PCCC) Recognition Program or other such programs that meet these criteria.", "measureId": "IA_PM_18", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "cehrtEligible": true }, { "title": "Glycemic Screening Services", "category": "ia", "description": "For at-risk outpatient Medicare beneficiaries, individual MIPS eligible clinicians and groups must attest to implementation of systematic preventive approaches in clinical practice for at least 60 percent for the 2018 performance period and 75 percent in future years, of electronic medical records with documentation of screening patients for abnormal blood glucose according to current US Preventive Services Task Force (USPSTF) and/or American Diabetes Association (ADA) guidelines.", "measureId": "IA_PM_19", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "cehrtEligible": true }, { "title": "Anticoagulant Management Improvements", "category": "ia", "description": "Individual MIPS eligible clinicians and groups who prescribe oral Vitamin K antagonist therapy (warfarin) must attest that, for 60 percent of practice patients in the transition year and 75 percent of practice patients in Quality Payment Program Year 2 and future years, their ambulatory care patients receiving warfarin are being managed by one or more of the following improvement activities: \n• Patients are being managed by an anticoagulant management service, that involves systematic and coordinated care, incorporating comprehensive patient education, systematic prothrombin time (PT-INR) testing, tracking, follow-up, and patient communication of results and dosing decisions;\n• Patients are being managed according to validated electronic decision support and clinical management tools that involve systematic and coordinated care, incorporating comprehensive patient education, systematic PT-INR testing, tracking, follow-up, and patient communication of results and dosing decisions;\n• For rural or remote patients, patients are managed using remote monitoring or telehealth options that involve systematic and coordinated care, incorporating comprehensive patient education, systematic PT-INR testing, tracking, follow-up, and patient communication of results and dosing decisions; and/or\n• For patients who demonstrate motivation, competency, and adherence, patients are managed using either a patient self-testing (PST) or patient-self-management (PSM) program.", "measureId": "IA_PM_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "populationManagement", "cehrtEligible": true }, { "title": "Glycemic Referring Services", "category": "ia", "description": "For at-risk outpatient Medicare beneficiaries, individual MIPS eligible clinicians and groups must attest to implementation of systematic preventive approaches in clinical practice for at least 60 percent for the CY 2018 performance period and 75 percent in future years, of medical records with documentation of referring eligible patients with prediabetes to a CDC-recognized diabetes prevention program operating under the framework of the National Diabetes Prevention Program.", "measureId": "IA_PM_20", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "cehrtEligible": true }, { "title": "Advance Care Planning", "category": "ia", "description": "Implementation of practices/processes to develop advance care planning that includes: documenting the advance care plan or living will within the medical record, educating clinicians about advance care planning motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement, educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation, as well as informing clinicians of the healthcare policy side of advance care planning.", "measureId": "IA_PM_21", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "cehrtEligible": true }, { "title": "RHC, IHS or FQHC quality improvement activities", "category": "ia", "description": "Participating in a Rural Health Clinic (RHC), Indian Health Service Medium Management (IHS), or Federally Qualified Health Center in ongoing engagement activities that contribute to more formal quality reporting , and that include receiving quality data back for broader quality improvement and benchmarking improvement which will ultimately benefit patients. Participation in Indian Health Service, as an improvement activity, requires MIPS eligible clinicians and groups to deliver care to federally recognized American Indian and Alaska Native populations in the U.S. and in the course of that care implement continuous clinical practice improvement including reporting data on quality of services being provided and receiving feedback to make improvements over time.", "measureId": "IA_PM_3", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "populationManagement", "cehrtEligible": false }, { "title": "Glycemic management services", "category": "ia", "description": "For outpatient Medicare beneficiaries with diabetes and who are prescribed antidiabetic agents (e.g., insulin, sulfonylureas), MIPS eligible clinicians and groups must attest to having: \nFor the first performance year, at least 60 percent of medical records with documentation of an individualized glycemic treatment goal that: \na) Takes into account patient-specific factors, including, at least 1) age, 2) comorbidities, and 3) risk for hypoglycemia, and\nb) Is reassessed at least annually.\n\nThe performance threshold will increase to 75 percent for the second performance year and onward.\nClinician would attest that, 60 percent for first year, or 75 percent for the second year, of their medical records that document individualized glycemic treatment represent patients who are being treated for at least 90 days during the performance period.", "measureId": "IA_PM_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "populationManagement", "cehrtEligible": true }, { "title": "Engagement of community for health status improvement", "category": "ia", "description": "Take steps to improve health status of communities, such as collaborating with key partners and stakeholders to implement evidenced-based practices to improve a specific chronic condition. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist MIPS eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.", "measureId": "IA_PM_5", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "cehrtEligible": false }, { "title": "Use of toolsets or other resources to close healthcare disparities across communities", "category": "ia", "description": "Take steps to improve healthcare disparities, such as Population Health Toolkit or other resources identified by CMS, the Learning and Action Network, Quality Innovation Network, or National Coordinating Center. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.", "measureId": "IA_PM_6", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "cehrtEligible": false }, { "title": "Use of QCDR for feedback reports that incorporate population health", "category": "ia", "description": "Use of a QCDR to generate regular feedback reports that summarize local practice patterns and treatment outcomes, including for vulnerable populations.", "measureId": "IA_PM_7", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "populationManagement", "cehrtEligible": false }, { "title": "Participation in population health research", "category": "ia", "description": "Participation in research that identifies interventions, tools or processes that can improve a targeted patient population.", "measureId": "IA_PM_9", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "cehrtEligible": false }, { "title": "Participation in an AHRQ-listed patient safety organization.", "category": "ia", "description": "Participation in an AHRQ-listed patient safety organization.", "measureId": "IA_PSPA_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "title": "Completion of training and receipt of approved waiver for provision opioid medication-assisted treatments", "category": "ia", "description": "Completion of training and obtaining an approved waiver for provision of medication -assisted treatment of opioid use disorders using buprenorphine.", "measureId": "IA_PSPA_10", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "title": "Participation in CAHPS or other supplemental questionnaire", "category": "ia", "description": "Participation in the Consumer Assessment of Healthcare Providers and Systems Survey or other supplemental questionnaire items (e.g., Cultural Competence or Health Information Technology supplemental item sets).", "measureId": "IA_PSPA_11", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "title": "Participation in private payer CPIA", "category": "ia", "description": "Participation in designated private payer clinical practice improvement activities.", "measureId": "IA_PSPA_12", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "title": "Participation in Joint Commission Evaluation Initiative", "category": "ia", "description": "Participation in Joint Commission Ongoing Professional Practice Evaluation initiative", "measureId": "IA_PSPA_13", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "title": "Participation in Quality Improvement Initiatives", "category": "ia", "description": "Participation in other quality improvement programs such as Bridges to Excellence or American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.", "measureId": "IA_PSPA_14", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "title": "Implementation of an ASP", "category": "ia", "description": "Change Activity Description to: Leadership of an Antimicrobial Stewardship Program (ASP) that includes implementation of an ASP that measures the appropriate use of antibiotics for several different conditions (such as but not limited to upper respiratory infection treatment in children, diagnosis of pharyngitis, bronchitis treatment in adults) according to clinical guidelines for diagnostics and therapeutics. Specific activities may include: \n• Develop facility-specific antibiogram and prepare report of findings with specific action plan that aligns with overall facility or practice strategic plan.\n• Lead the development, implementation, and monitoring of patient care and patient safety protocols for the delivery of ASP including protocols pertaining to the most appropriate setting for such services (i.e., outpatient or inpatient). \n• Assist in improving ASP service line efficiency and effectiveness by evaluating and recommending improvements in the management structure and workflow of ASP processes.\n• Manage compliance of the ASP policies and assist with implementation of corrective actions in accordance with facility or clinic compliance policies and hospital medical staff by-laws. \n• Lead the education and training of professional support staff for the purpose of maintaining an efficient and effective ASP.\n• Coordinate communications between ASP management and facility or practice personnel regarding activities, services, and operational/clinical protocols to achieve overall compliance and understanding of the ASP.\n• Assist, at the request of the facility or practice, in preparing for and responding to third-party requests, including but not limited to payer audits, governmental inquiries, and professional inquiries that pertain to the ASP service line. \n• Implementing and tracking an evidence-based policy or practice aimed at improving antibiotic prescribing practices for high-priority conditions. \n• Developing and implementing evidence-based protocols and decision-support for diagnosis and treatment of common infections.\n• Implementing evidence-based protocols that align with recommendations in the Centers for Disease Control and Prevention’s Core Elements of Outpatient Antibiotic Stewardship guidance", "measureId": "IA_PSPA_15", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "title": "Use of decision support and standardized treatment protocols", "category": "ia", "description": "Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs.", "measureId": "IA_PSPA_16", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": true }, { "title": "Implementation of analytic capabilities to manage total cost of care for practice population", "category": "ia", "description": "Build the analytic capability required to manage total cost of care for the practice population that could include one or more of the following: \n\nTrain appropriate staff on interpretation of cost and utilization information; and/or\n\nUse available data regularly to analyze opportunities to reduce cost through improved care.", "measureId": "IA_PSPA_17", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "title": "Measurement and Improvement at the Practice and Panel Level", "category": "ia", "description": "Measure and improve quality at the practice and panel level, such as the American Board of Orthopaedic Surgery (ABOS) Physician Scorecards, that could include one or more of the following:\n• Regularly review measures of quality, utilization, patient satisfaction and other measures that may be useful at the practice level and at the level of the care team or MIPS eligible clinician or group (panel); and/or \n• Use relevant data sources to create benchmarks and goals for performance at the practice level and panel level.", "measureId": "IA_PSPA_18", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "title": "Implementation of formal quality improvement methods, practice changes, or other practice improvement processes", "category": "ia", "description": "Adopt a formal model for quality improvement and create a culture in which all staff actively participates in improvement activities that could include one or more of the following such as: \n• Multi-Source Feedback; \n• Train all staff in quality improvement methods; \n• Integrate practice change/quality improvement into staff duties; \n• Engage all staff in identifying and testing practices changes; \n• Designate regular team meetings to review data and plan improvement cycles; \n• Promote transparency and accelerate improvement by sharing practice level and panel level quality of care, patient experience and utilization data with staff; and/or \n• Promote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data.", "measureId": "IA_PSPA_19", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "title": "Participation in MOC Part IV", "category": "ia", "description": "Participation in Maintenance of Certification (MOC) Part IV, such as the American Board of Internal Medicine (ABIM) Approved Quality Improvement (AQI) Program, National Cardiovascular Data Registry (NCDR) Clinical Quality Coach, Quality Practice Initiative Certification Program, American Board of Medical Specialties Practice Performance Improvement Module or ASA Simulation Education Network, for improving professional practice including participation in a local, regional or national outcomes registry or quality assessment program. Performance of monthly activities across practice to regularly assess performance in practice, by reviewing outcomes addressing identified areas for improvement and evaluating the results.", "measureId": "IA_PSPA_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "title": "Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes", "category": "ia", "description": "Ensure full engagement of clinical and administrative leadership in practice improvement that could include one or more of the following: \n\nMake responsibility for guidance of practice change a component of clinical and administrative leadership roles; \n\nAllocate time for clinical and administrative leadership for practice improvement efforts, including participation in regular team meetings; and/or\n\nIncorporate population health, quality and patient experience metrics in regular reviews of practice performance.", "measureId": "IA_PSPA_20", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "title": "Implementation of fall screening and assessment programs", "category": "ia", "description": "Implementation of fall screening and assessment programs to identify patients at risk for falls and address modifiable risk factors (e.g., Clinical decision support/prompts in the electronic health record that help manage the use of medications, such as benzodiazepines, that increase fall risk).", "measureId": "IA_PSPA_21", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "title": "CDC Training on CDC’s Guideline for Prescribing Opioids for Chronic Pain", "category": "ia", "description": "Completion of all the modules of the Centers for Disease Control and Prevention (CDC) course “Applying CDC’s Guideline for Prescribing Opioids” that reviews the 2016 “Guideline for Prescribing Opioids for Chronic Pain.” Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.", "measureId": "IA_PSPA_22", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "title": "Completion of CDC Training on Antibiotic Stewardship", "category": "ia", "description": "Completion of all modules of the Centers for Disease Control and Prevention antibiotic stewardship course. Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.", "measureId": "IA_PSPA_23", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "title": "Initiate CDC Training on Antibiotic Stewardship", "category": "ia", "description": "Completion of greater than 50 percent of the modules of the Centers for Disease Control and Prevention antibiotic stewardship course. Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis, but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.", "measureId": "IA_PSPA_24", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "title": "Cost Display for Laboratory and Radiographic Orders", "category": "ia", "description": "Implementation of a cost display for laboratory and radiographic orders, such as costs that can be obtained through the Medicare clinical laboratory fee schedule.", "measureId": "IA_PSPA_25", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": true }, { "title": "Communication of Unscheduled Visit for Adverse Drug Event and Nature of Event", "category": "ia", "description": "A MIPS eligible clinician providing unscheduled care (such as an emergency room, urgent care, or other unplanned encounter) attests that, for greater than 75 percent of case visits that result from a clinically significant adverse drug event, the MIPS eligible clinician provides information, including through the use of health IT to the patient’s primary care clinician regarding both the unscheduled visit and the nature of the adverse drug event within 48 hours. A clinically significant adverse event is defined as a medication-related harm or injury such as side-effects, supratherapeutic effects, allergic reactions, laboratory abnormalities, or medication errors requiring urgent/emergent evaluation, treatment, or hospitalization.", "measureId": "IA_PSPA_26", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": true }, { "title": "Invasive Procedure or Surgery Anticoagulation Medication Management", "category": "ia", "description": "For an anticoagulated patient undergoing a planned invasive procedure for which interruption in anticoagulation is anticipated, including patients taking vitamin K antagonists (warfarin), target specific oral anticoagulants (such as apixaban, dabigatran, and rivaroxaban), and heparins/low molecular weight heparins, documentation, including through the use of electronic tools, that the plan for anticoagulation management in the periprocedural period was discussed with the patient and with the clinician responsible for managing the patient’s anticoagulation. Elements of the plan should include the following: discontinuation, resumption, and, if applicable, bridging, laboratory monitoring, and management of concomitant antithrombotic medications (such as antiplatelets and nonsteroidal anti-inflammatory drugs (NSAIDs)). An invasive or surgical procedure is defined as a procedure in which skin or mucous membranes and connective tissue are incised, or an instrument is introduced through a natural body orifice.", "measureId": "IA_PSPA_27", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "title": "Completion of an Accredited Safety or Quality Improvement Program", "category": "ia", "description": "Completion of an accredited performance improvement continuing medical education program that addresses performance or quality improvement according to the following criteria:\n• The activity must address a quality or safety gap that is supported by a needs assessment or problem analysis, or must support the completion of such a needs assessment as part of the activity;\n• The activity must have specific, measurable aim(s) for improvement;\n• The activity must include interventions intended to result in improvement;\n• The activity must include data collection and analysis of performance data to assess the impact of the interventions; and\nThe accredited program must define meaningful clinician participation in their activity, describe the mechanism for identifying clinicians who meet the requirements, and provide participant completion information.", "measureId": "IA_PSPA_28", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "title": "Consulting AUC Using Clinical Decision Support when Ordering Advanced", "category": "ia", "description": "Clinicians attest that they are consulting specified applicable AUC through a qualified clinical decision support mechanism for all applicable imaging services furnished in an applicable setting, paid for under an applicable payment system, and ordered on or after January 1, 2018. This activity is for clinicians that are early adopters of the Medicare AUC program (2018 performance year) and for clinicians that begin the Medicare AUC program in future years as specified in our regulation at §414.94. The AUC program is required under section 218 of the Protecting Access to Medicare Act of 2014. Qualified mechanisms will be able to provide a report to the ordering clinician that can be used to assess patterns of image-ordering and improve upon those patterns to ensure that patients are receiving the most appropriate imaging for their individual condition.", "measureId": "IA_PSPA_29", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": true }, { "title": "Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS® or Other Similar Activity", "category": "ia", "description": "For MIPS eligible clinicians not participating in Maintenance of Certification (MOC) Part IV, new engagement for MOC Part IV, such as the Institute for Healthcare Improvement (IHI) Training/Forum Event; National Academy of Medicine, Agency for Healthcare Research and Quality (AHRQ) Team STEPPS®, or the American Board of Family Medicine (ABFM) Performance in Practice Modules.", "measureId": "IA_PSPA_3", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "title": "PCI Bleeding Campaign", "category": "ia", "description": "Participation in the PCI Bleeding Campaign which is a national quality improvement program that provides infrastructure for a learning network and offers evidence-based resources and tools to reduce avoidable bleeding associated with patients who receive a percutaneous coronary intervention (PCI).\n\nThe program uses a patient-centered and team-based approach, leveraging evidence-based best practices to improve care for PCI patients by implementing quality improvement strategies:\n• Radial-artery access,\n• Bivalirudin, and\n• Use of vascular closure devices.", "measureId": "IA_PSPA_30", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "title": "Administration of the AHRQ Survey of Patient Safety Culture", "category": "ia", "description": "Administration of the AHRQ Survey of Patient Safety Culture and submission of data to the comparative database (refer to AHRQ Survey of Patient Safety Culture website http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html).Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.", "measureId": "IA_PSPA_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "title": "Annual registration in the Prescription Drug Monitoring Program", "category": "ia", "description": "Annual registration by eligible clinician or group in the prescription drug monitoring program of the state where they practice. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and groups must participate for a minimum of 6 months.", "measureId": "IA_PSPA_5", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "title": "Consultation of the Prescription Drug Monitoring Program", "category": "ia", "description": "Clinicians would attest to reviewing the patients’ history of controlled substance prescription using state prescription drug monitoring program (PDMP) data prior to the issuance of a Controlled Substance Schedule II (CSII) opioid prescription lasting longer than 3 days. For the transition year, clinicians would attest to 60 percent review of applicable patient’s history. For the Quality Payment Program Year 2 and future years, clinicians would attest to 75 percent review of applicable patient’s history performance.", "measureId": "IA_PSPA_6", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "title": "Use of QCDR data for ongoing practice assessment and improvements", "category": "ia", "description": "Use of QCDR data, for ongoing practice assessment and improvements in patient safety.", "measureId": "IA_PSPA_7", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "title": "Use of Patient Safety Tools", "category": "ia", "description": "Use of tools that assist specialty practices in tracking specific measures that are meaningful to their practice, such as use of a surgical risk calculator, evidence based protocols such as Enhanced Recovery After Surgery (ERAS) protocols, the CDC Guide for Infection Prevention for Outpatient Settings, (https://www.cdc.gov/hai/settings/outpatient/outpatient-care-guidelines.html), predictive algorithms, or other such tools.", "measureId": "IA_PSPA_8", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "title": "Completion of the AMA STEPS Forward program", "category": "ia", "description": "Completion of the American Medical Association’s STEPS Forward program.", "measureId": "IA_PSPA_9", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "cehrtEligible": false }, { "category": "cost", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "costScore", "title": "Medicare Spending Per Beneficiary (MSPB)", "description": "The Medicare Spending Per Beneficiary (MSPB) measure evaluates solo practitioners and groups on their spending efficiency and is risk-adjusted to account for patients' risk profiles. Solo practitioners and groups are identified by their National Provider Identification (NPI) and Taxpayer Identification Number (TIN) combination. Specifically, the MSPB measure assesses the average spend for Medicare services performed by providers/groups per episode of care. Each episode comprises the period immediately prior to, during, and following a patient's hospital stay.", "measureId": "MSPB_1", "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ] }, { "category": "cost", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "costScore", "title": "Total Per Capita Costs (TPCC)", "description": "The Total Per Capita Costs (TPCC) measure is a payment-standardized, annualized, risk-adjusted, and specialty-adjusted measure that evaluates the overall efficiency of care provided to beneficiaries attributed to solo practitioners and groups, as identified by their Medicare Taxpayer Identification Number (TIN)", "measureId": "TPCC_1", "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "cahps", "title": "CAHPS for MIPS SSM: Getting Timely Care, Appointments and Information", "description": "", "nationalQualityStrategyDomain": null, "measureType": "patientEngagementExperience", "measureId": "CAHPS_1", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0005", "isInverse": false, "strata": [], "isHighPriority": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "primarySteward": "Agency for Healthcare Research & Quality", "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ], "isRegistryMeasure": false }, { "category": "quality", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "metricType": "cahps", "title": "CAHPS for ACO SSM: Getting Timely Care, Appointments and Information", "description": "", "nationalQualityStrategyDomain": null, "measureType": "patientEngagementExperience", "measureId": "CAHPS_ACO_1", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [], "isHighPriority": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "primarySteward": "Agency for Healthcare Research & Quality", "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ], "isRegistryMeasure": false }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "cahps", "title": "CAHPS for MIPS SSM: How Well Providers Communicate", "description": "", "nationalQualityStrategyDomain": null, "measureType": "patientEngagementExperience", "measureId": "CAHPS_2", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0005", "isInverse": false, "strata": [], "isHighPriority": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "primarySteward": "Agency for Healthcare Research & Quality", "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ], "isRegistryMeasure": false }, { "category": "quality", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "metricType": "cahps", "title": "CAHPS for ACO SSM: How Well Providers Communicate", "description": "", "nationalQualityStrategyDomain": null, "measureType": "patientEngagementExperience", "measureId": "CAHPS_ACO_2", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [], "isHighPriority": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "primarySteward": "Agency for Healthcare Research & Quality", "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ], "isRegistryMeasure": false }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "cahps", "title": "CAHPS for MIPS SSM: Patient’s Rating of Provider", "description": "", "nationalQualityStrategyDomain": null, "measureType": "patientEngagementExperience", "measureId": "CAHPS_3", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [], "isHighPriority": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "primarySteward": "Agency for Healthcare Research & Quality", "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ], "isRegistryMeasure": false }, { "category": "quality", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "metricType": "cahps", "title": "CAHPS for ACO SSM: Patient’s Rating of Provider", "description": "", "nationalQualityStrategyDomain": null, "measureType": "patientEngagementExperience", "measureId": "CAHPS_ACO_3", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [], "isHighPriority": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "primarySteward": "Agency for Healthcare Research & Quality", "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ], "isRegistryMeasure": false }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "cahps", 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null, "measureId": "ACO321", "description": "Getting timely care, appointments, and information; How well providers Communicate; Patient's Rating of Provider; Access to Specialists; Health Promotion & Education; Shared Decision Making; Health Status/Functional Status; and Stewardship of Patient Resources", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientEngagementExperience", "primarySteward": "Agency for Healthcare Research & Quality", "metricType": "cahps", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isToppedOutByProgram": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine", "internalMedicine" ], "measureSpecification": {} }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, 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2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAD3", "title": "Basal Cell Carcinoma/Squamous Cell Carcinoma: Mohs Surgery for Superficial Basal Cell Carcinoma of the Trunk for Immune Competent Patients", "description": "The percentage of immune‐competent patients with pathologically‐proven primary superficial basal cell carcinoma (BCC) lesions on the trunk (chest, back, abdomen) who are treated with Mohs surgery.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "AAD'S DataDerm", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, 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"category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAD5", "title": "Biopsy: Reporting Time - Clinician to Patient", "description": "Percentage of patients with skin biopsy specimens with a diagnosis of cutaneous basal or squamous cell carcinoma (including in situ disease) who are notified of their final biopsy pathology findings within less than or equal to 14 days from the time the biopsy was performed.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAD'S DataDerm", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN1", "title": "Diabetes/Pre-Diabetes Screening for Patients with DSP", "description": "Percentage of patients age 18 years and older with a diagnosis of distal symmetric\npolyneuropathy who had screening tests for diabetes (eg fasting blood sugar test, a hemoglobin\nA1C, or a 2 hour Glucose Tolerance Test) reviewed, requested or ordered when seen for an\ninitial evaluation for distal symmetric polyneuropathy.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], 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"registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN11", "title": "Overuse of barbiturate and opioid containing medications for primary headache disorders", "description": "Percentage of patients age 12 years and older with a diagnosis of primary headache who were prescribed opioid or barbiturate containing medications assessed for medication overuse headache within the 12-month measurement period, and if identified as overusing opioid or barbiturate containing medication, treated or referred for treatment.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN12", "title": "Quality of Life Assessment for Patients with Epilepsy", "description": "Percentage of patients whose quality of life assessment results are maintained or improved during the measurement period.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN14", "title": "Current MS Disability Scale Score", "description": "Percentage of patients with MS who have a MS disability scale score* documented in the medical record in the past 12 months and had appropriate follow up", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN15", "title": "Quality of Life Assessment", "description": "Percentage of patients age 18 years and older with a neurologic condition who had a PROMIS-29 administered, the results reviewed and had appropriate follow up", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN16", "title": "Falls Outcome for Patients with Parkinson's Disease", "description": "Percentage of patients diagnosed with PD for who the number of falls was maintained or reduced from initial baseline.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN18", "title": "First line treatment for infantile spasms (IS)", "description": "Percentage of patients receiving appropriate first line treatment for infantile spasms (IS)", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN19", "title": "Botulinum Toxin Serotype A (BoNT-A) for spasticity or dystonia", "description": "Percentage of patients with spasticity or dystonia who were evaluated or referred or treated with BoNTA", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN2", "title": "DSP Screening for Unhealthy Alcohol Use", "description": "Patients with a diagnosis of DSP who were screened with a validated screening instrument for unhealthy alcohol use* at time of initial diagnosis and once yearly for those with prior diagnosis, and if screening was positive, brief counseling provided.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN20", "title": "Querying for co-morbid conditions of tic disorder (TD) and Tourette syndrome (TS)", "description": "Percentage of patients who were queried for psychological and/or behavioral co-morbid conditions of\ntic disorder (TD) or Tourette syndrome (TS)", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN4", "title": "Screening for Psychiatric or Behavioral Health Disorders", "description": "Percent of all visits for patients with a diagnosis of epilepsy where the patient was screened for\npsychiatric or behavioral disorders.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN5", "title": "MEDICATION PRESCRIBED FOR ACUTE MIGRAINE ATTACK", "description": "Percentage of patients age 12 years and older with a diagnosis of migraine who were prescribed a guideline\nrecommended medication for acute migraine attacks within the 12 month measurement period.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN8", "title": "Exercise and Appropriate Physical Activity Counseling for Patients with MS", "description": "Percentage of patients with MS who are counseled* on the benefits of exercise and appropriate\nphysical activity for patients with MS in the past 12 months.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN9", "title": "Querying About Symptoms of Autonomic Dysfunction for Patients with Parkinson's Disease", "description": "Percentage of all patients with a diagnosis of PD (or caregivers, as appropriate) who were queried about symptoms of autonomic dysfunction* in the past 12 months and if autonomic dysfunction identified had appropriate follow-up.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO11", "title": "Otitis Media with Effusion: Avoidance of Topical Intranasal Corticosteroids", "description": "Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed topical intranasal corticosteroids", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO12", "title": "Topical Ear Drop Monotherapy for Children with Acute Tympanostomy Tube Otorrhea", "description": "Percentage of patients age 6 months to 12 years of age at the time of the visit with a current diagnosis of an uncomplicated acute tympanostomy tube otorrhea who were prescribed or recommended to use topical antibiotic eardrops and NOT prescribed oral antibiotics for acute tympanostomy tube otorrhea.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO13", "title": "Inappropriate Use of Magnetic Resonance Imaging or Computed Tomography Scan for Bell’s Palsy (Inverse Measure)", "description": "Percentage of patients age 16 years and older with a new onset diagnosis of Bell’s Palsy within the past 3 months who had a magnetic resonance imaging (MRI) or a computed tomography scan (CT) of the internal auditory canal, head, neck or brain ordered for the primary diagnosis of Bell’s palsy.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO14", "title": "Inappropriate Use of Antiviral Monotherapy for Bell’s Palsy (Inverse Measure)", "description": "Percentage of patients age 16 years and older with a new-onset diagnosis of Bell’s palsy within the past 3 months who were prescribed antiviral therapy without concurrent systemic steroid therapy for the treatment of Bell’s palsy.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO15", "title": "Percentage of patients with cerumen impaction and a suggestive history of a non-intact tympanic membrane who receive just manual removal.", "description": "This measure is intended to improve management of cerumen impaction in patients with non-intact tympanic membrane where appropriate management options are constrained.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO16", "title": "Audiometric Evaluation for Older Adults with Hearing Loss", "description": "Percentage of patients age 60 years and older who failed a hearing screening and who received, were ordered or were referred for comprehensive audiometric testing within 4 weeks of failing the hearing screening.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO17", "title": "Advanced Diagnostic Imaging of Bilateral Presbycusis or Symmetric Sensorineural Hearing Loss-Avoidance of Inappropriate Use", "description": "Percentage of patients age 60 years and older with a diagnosis of bilateral presbycusis or symmetric sensorineural hearing loss who were NOT ordered magnetic resonance imaging (MRI) or a computed tomography scan (CT scan) of the brain, temporal bone or internal auditory canal for the primary indication of bilateral presbycusis or symmetric sensorineural hearing loss.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO18", "title": "Percentage of visits with patients with hearing aids where otoscopy is routinely performed", "description": "Patients with hearing aids should be assessed frequently using otoscopy. Even when presenting for a clinical complaint not associated with hearing or hearing aids, a clinical encounter can be an opportunity to assess for factors that would impact the function of the hearing aids. It is recognized that patients coming into the office for non-hearing related complaints may have recently been assessed and that clinicians may be appropriately care for a patient despite not assessing with otoscopy at every single visit. A three month look back period for additional visits where otoscopy was performed was deemed to be satisfactory.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO19", "title": "Shared Decision Making for Treatment Options for Bilateral Presbycusis or Symmetric Sensorineural Hearing Loss", "description": "Percentage of patients age 60 years and older with a diagnosis of bilateral presbycusis symmetric sensorineural hearing loss or their caregiver(s) who participated in shared decision making regarding treatment options for bilateral presbycusis or sensorineural hearing loss.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO20", "title": "Otitis Media with Effusion: Hearing Testing", "description": "Percentage of patients aged 2 months through 12 years with a diagnosis of OME who received tympanostomy tube insertion who had a hearing test performed within 6 months prior to tympanostomy tube insertion", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO21", "title": "Audiometry for Chronic Otitis Media with Effusion in Children", "description": "Percentage of patients age 6 months to 12 years of age at the time of the visit with a diagnosis of otitis media with effusion including chronic serous, mucoid, or nonsuppurative otitis media with effusion of ≥3 months duration who had audiometry performed, ordered or who were referred for an audiometric evaluation.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO22", "title": "Percentage of patients with allergic rhinitis who do not receive sinonasal imaging for allergic rhinitis", "description": "This measure is intended to decrease inappropriate imaging in patients with allergic rhinitis who do not have asthma.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO23", "title": "Percentage of patients with allergic rhinitis who are offered intranasal corticosteroids or oral antihistamines", "description": "This measure is intended to decrease variability in management of allergic rhinitis by clinicians and encouraging the use of intranasal steroids or oral antihistamines for treatment of allergic rhinitis as first line treatment.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO24", "title": "Percentage of patients with allergic rhinitis who do not receive leukotriene inhibitors", "description": "This measure is intended to decrease inappropriate prescription of leukotriene inhibitors to patients with allergic rhinitis who do not have asthma.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO25", "title": "Percentage of patients with allergic rhinitis who do not receive IgG-based immunoglobulin testing", "description": "This measure is intended to improve appropriate test selection for patients with allergic rhinitis undergoing evaluations for allergens.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO26", "title": "Otitis Media with Effusion: Diagnostic Evaluation - Assessment of Tympanic Membrane Mobility", "description": "Percentage of patient visits for those patients aged 2 months through 12 years with a diagnosis of OME with assessment of tympanic membrane mobility with pneumatic otoscopy or tympanometry", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO27", "title": "Otitis Media with Effusion: Resolution of Otitis Media with Effusion in Children", "description": "Percentage of patients aged 6 months to 12 years with a diagnosis of OME who have resolution of effusion between 2 and 8 weeks after tympanostomy tube insertion", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO28", "title": "Otitis Media with Effusion: Resolution of Otitis Media with Effusion in Adults", "description": "Percentage of patients >12 years of age with a diagnosis of OME who have resolution of effusion between 2 and 8 weeks after tympanostomy tube insertion", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO8", "title": "Otitis Media with Effusion: Antihistamines or Decongestants – Avoidance of Inappropriate Use", "description": "Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed or recommended to receive either antihistamines or decongestants", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABFM1", "title": "All Patients Who Die an Expected Death with an ICD that Has Been Deactivated", "description": "Percentage of adult 18 and older patients in any care setting who die an expected death from cancer or other terminal illness and who have an implantable cardioverter-defibrillator (ICD) in place at the time of death that was deactivated prior to death or there is documentation why it was not deactivated", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABFM PRIME", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABFM2", "title": "Patients Admitted to ICU who Have Care Preferences Documented", "description": "Percentage of adult 18 and older patients admitted to ICU who receive palliative care and survive at least 2 days who have their care preferences documented within 2 days OR documentation as to why this was not done.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABFM PRIME", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABFM3", "title": "Patients Treated with an Opioid Who Are Given a Bowel Regimen", "description": "Percentage of adults 18 and older treated with an opioid that are offered/prescribed a bowel regimen during the same visit or documentation of reason for why this was not needed", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABFM PRIME", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABFM4", "title": "Palliative Care – Spiritual Assessment", "description": "Percentage of adult patients 18 and older and/or their caregiver receiving a palliative care visit with documentation of a discussion of spiritual/religious concerns or documentation that the they did not want to discuss during the first three visits", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABFM PRIME", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABFM5", "title": "Palliative Care—Treatment Preferences", "description": "The percentage of adult patients 18 and older with documentation of preferences for life-sustaining treatments within the first three visits", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABFM PRIME", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABFM6", "title": "Palliative Care Timely Dyspnea Screening & Treatment", "description": "Percentage of palliative care adult patients 18 years and older who were screened for dyspnea during the initial palliative care encounter or documentation that a screening was attempted AND for those with moderate/severe dyspnea or who are uncomfortable due to dyspnea who receive treatment within 1 day of screening.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABFM PRIME", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABFM7", "title": "Pain Brought Under Control within the first three visits", "description": "Percent of patients 18 and older who report being uncomfortable because of pain at the initial palliative care assessment who report pain was brought to a comfortable level (e.g. “Comfortable? Yes/No”, “mild” or pain score < 4) within the first three visits", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABFM PRIME", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABFM8", "title": "Measuring the Value-Functions of Primary Care: Provider Level Continuity Measure", "description": "Bice-Boxerman Continuity of Care Primary Care Physician Measure (BB-COC-PC).\n\nAt a patient-level, BB-COC is a measure that considers the dispersion of primary care visits across providers, such that patients with higher scores have most of their primary care visits to the same provider or a small number of providers while those lower scores see a larger number providers. Formally, an individual BB-COC score is calculated as follows:\n\nBB-COC=(∑_(i=1)^k n_i^2 -N)/(N(N-1)) (1)\n\nwhere k is the number of providers, n_i is the number of visits to provider i, and N is the total number of visits. (Note that it is necessary that the patient has at least two visits.)\nWe will calculate the physician-level continuity measure for all patients as follows:\n\nBB-COC-PC=(∑_1^k 〖((BB-COC)(n_k ))〗)/(N*(n_k)) (2)\n\nWhere BB-COC is the individual patient continuity score, n is number of total primary care visits for patient k during the study period, and N is the total number of patients seen by the physicians during the study period. This approach gives greater weight to patients with more visits.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "structure", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABFM PRIME", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABG1", "title": "Intra-operative anesthesia safety", "description": "Percentage of patients with no significant anesthesia adverse events in the operating room/procedure room.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABG QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABG16", "title": "Planned use of difficult airway equipment", "description": "For all patients on whom difficult airway equipment is used in the operating room/procedure room during an anesthetic, the rate with which it's use is planned ahead of time for either therapeutic or educational purposes.\n\nThe definition of difficult airway equipment for this measure excludes stylets and/or bougies unless they have been modified to include a light source or some other mechanical addition to manipulate their placement.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABG QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABG21", "title": "Pre-operative OSA assessment", "description": "Percentage of patients who undergo a surgical procedure in the operating room/procedure room that have a pre-operative assessment for Obstructive Sleep Apnea (OSA)", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABG QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABG28", "title": "Pre-Operative Screening for GERD", "description": "Percentage of patients that undergo an anesthetic in the operating room/procedure room who are questioned about symptoms of Gastroesophageal Reflux Disease during their pre-anesthetic evaluation", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABG QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABG29", "title": "Pre-Operative Screening for Glaucoma", "description": "Percentage of patients that undergo an anesthetic in the operating room/procedure room who are questioned about a history of Glaucoma or elevated eye pressures during their pre-anesthetic evaluation", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABG QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABG30", "title": "Pre-Operative Screening for PONV Risk", "description": "Percentage of patients that undergo an anesthetic in the operating room/procedure room who are questioned about Post-operative Nausea and Vomiting risk factors during their pre-anesthetic evaluation", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABG QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABG31", "title": "Pre-Operative Screening for Excessive Alcohol and Recreational Drug Use", "description": "Percentage of patients that undergo an anesthetic in the operating room/procedure room who are questioned about alcohol and recreational drug use during their pre-anesthetic evaluation", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABG QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABG32", "title": "Pain Related Quality of Life Interference", "description": "Percentage of patients with a diagnosis of chronic pain whose pain related quality of life (QOL) interference is addressed during at least two office visits throughout the calendar year.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABG QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABG33", "title": "Lower Body Functional Impairment (LBI)", "description": "Percentage of patients with a diagnosis of chronic pain whose functional status was assessed with a tool(s) during at least two office visits throughout the calendar year of treatment and whose pain related functional status stayed the same or improved.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABG QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABG34", "title": "Mood Assessment Screening and treatment", "description": "Percentage of patients with a diagnosis of chronic pain who were assessed for depression and anxiety with a standardized tool at least twice in the calendar year and who are treated for mood disorders during the calendar year as a result of their elevated assessment scores.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABG QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABG35", "title": "Preoperative Assessment of Frailty", "description": "Percentage of patients that undergo an anesthetic in the operating room/procedure room who are assessed for Frailty during their pre-anesthetic evaluation using a 7 point scoring system. The following 7 components each count as 1 point if threshold measurements are exceeded: Charlson Comorbidity Index, Hematocrit, Katz score of ADL, Up-to-Go test, Mini Cog test, unintended weight loss assessment and falls within 6 months prior to visit. Scores > or equal to 4 are frail, 2-3 are pre-frail, and <2 is normal.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABG QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABG36", "title": "Corneal Abrasion", "description": "Percentage of patients having an anesthetic in the operating room/procedure room who experience any ocular surface injury requiring evaluation, follow up, or treatment within 24 hours of anesthesia end time.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ABG QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABG7", "title": "Immediate Adult Post-Operative Pain Management", "description": "The percentage of patients 18 or older admitted to the PACU after an anesthetic with a maximum pain score <7/10 prior to anesthesia end time.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABG QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACCPIN3", "title": "ACCPin3 Heart Failure: Patient Self Care Education", "description": "Patients, age 18 and older, with a principle diagnosis of heart failure (LVEF <40) who received educational counseling on weight monitoring, sodium restriction, physical activity and medication instruction.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pinnacle Registry and Diabetes Collaborative Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP19", "title": "Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older", "description": "Percentage of emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP20", "title": "Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years", "description": "Percentage of emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the PECARN prediction rules for traumatic brain injury", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP21", "title": "Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or Bleeding", "description": "Percentage of emergency department visits for patients aged 18 years and older with an emergency department discharge diagnosis of chest pain during which coagulation studies were ordered by an emergency care provider", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP22", "title": "Appropriate Emergency Department Utilization of CT for Pulmonary Embolism", "description": "Percentage of emergency department visits during which patients aged 18 years and older had a CT pulmonary angiogram (CTPA) ordered by an emergency care provider, regardless of discharge disposition, with either moderate\nor high pre-test clinical probability for pulmonary embolism OR positive result or elevated D-dimer level", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP24", "title": "Pregnancy Test for Female Abdominal Pain Patients", "description": "Percentage of emergency department visits for female patients aged 14 through 50 years old who present to the ED with a chief complaint of abdominal pain who have had a pregnancy test (urine or serum) ordered", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP25", "title": "Tobacco Use: Screening and Cessation Intervention for Patients with Asthma and COPD", "description": "Percentage of patients aged 18 years and older with a diagnosis of asthma or COPD seen in the ED who were screened for tobacco use during any ED encounter AND who received tobacco cessation intervention if identified as a tobacco user", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP29", "title": "Sepsis Management: Septic Shock: Repeat Lactate Level Measurement", "description": "Percentage of emergency department visits for patients aged 18 years and older with septic shock and an elevated serum lactate result (>2mmol/L) with a second serum lactate measurement ordered following the elevated serum lactate result during the emergency department visit", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP30", "title": "Sepsis Management: Septic Shock: Lactate Clearance Rate of >=10%", "description": "Percentage of emergency department visits for patients aged 18 years and older with septic shock who had an elevated serum lactate result (>2mmol/L) and a subsequent serum lactate level measurement performed following the elevated serum lactate result with a lactate clearance rate of >= 10% during the emergency department visit", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP31", "title": "Appropriate Foley Catheter Use in the Emergency Department", "description": "Percentage of emergency department (ED) visits for admitted patients aged 18 years and older where an indwelling Foley catheter is ordered and the patient had at least one indication for an indwelling Foley catheter", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP32", "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients", "description": "Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients (Excluding Psych and Mental Health, and Transfer Patients)", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP33", "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Supercenter EDs\n(80k +)", "description": "Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients in Supercenter EDs (80k+)", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry 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null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP36", "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Average Volume EDs (40k-59,999)", "description": "Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients in Average Volume EDs (40k-59,999)", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP37", "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Moderate Volume EDs (20k-39,999)", "description": "Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients in Moderate Volume EDs (20k-39,999)", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP38", "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Low Volume EDs (19,999 and less)", "description": "Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients in Low Volume EDs (19,999 and less)", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP39", "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Freestanding Ends", "description": "Time 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"nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP41", "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Supercenter EDs (80k +)", "description": "Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients in Supercenter EDs (80k+)", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP43", "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in High Volume EDs (60k-79,999)", "description": "Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients in High Volume EDs (60k-79,999", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data 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null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP45", "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Moderate Volume EDs (20k-39,999)", "description": "Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients in Moderate Volume EDs (20k-39,999)", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP46", "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Low Volume EDs (19,999 and less)", "description": "Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients in Low Volume EDs (19,999 and less)", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP47", "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Freestanding EDs", "description": "Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients in Freestanding EDs", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP48", "title": "Sepsis Management: Septic Shock: Lactate Level Management, Antibiotics Ordered, and Fluid Resuscitation", "description": "Percentage of emergency department visits for patients aged 18 years and older with septic shock who had an order for all of the following during the emergency department visit: a serum lactate level, antibiotics, and >1L of crystalloids", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACMT1", "title": "Screening for risk of opioid misuse/overuse", "description": "Percentage of patients aged 12 years or older who were screened for the potential risk of opioid misuse/overuse", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Medical Toxicology (ACMT) ToxIC Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACMT2", "title": "Pregnancy test in women who receive a toxicologic consult", "description": "Percentage of women of childbearing age (12-60 years) who are seen by a medical toxicologist in the emergency department or inpatient setting and receive a pregnancy test prior to emergency department discharge or within 24 hours of hospital admission.", "nationalQualityStrategyDomain": "Effective 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"firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACMT4", "title": "Appropriate treatment for acetaminophen ingestions", "description": "% of patients of any age with an acetaminophen ingestion for which n-acetylcysteine (NAC) was initiated and discontinued appropriately", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Medical Toxicology (ACMT) ToxIC Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACMT5", "title": "Assessment of suspected ethylene glycol or methanol exposures", "description": "Percentage of patients of any age with suspected exposure to ethylene glycol or methanol for whom appropriate laboratory testing was performed within 4 hours of hospital presentation.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Medical Toxicology (ACMT) ToxIC Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACMT6", "title": "Repeat assessment of salicylate concentrations in overdose patients", "description": "Percentage of patients of any age with suspected drug overdose with an initial plasma salicylate concentration >15 mg/dL who had a second plasma salicylate concentration sample collected within 4 hours following the time the initial sample was obtained", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Medical Toxicology (ACMT) ToxIC Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACPGR1", "title": "High Risk Pneumococcal Vaccination", "description": "The percentage of patients aged 19 through 64 with a high risk condition, who either received a pneumococcal vaccination OR who reported previous receipt of a pneumococcal vaccination.", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Physicians Genesis Registry, Powered by Premier, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACPGR2", "title": "Tdap (Tetanus, Diphtheria, Acellular Pertussis) Vaccination", "description": "Percentage of patients aged 19 or older who received a primary vaccine series of tetanus/diphtheria/acellular pertussis (tdap) vaccine OR who reported previous receipt of Tdap booster vaccination.", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Physicians Genesis Registry, Powered by Premier, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACPGR3", "title": "Fixed-dose Combination of Hydralazine and Isosorbide Dinitrate Therapy for Self-identified Black or African American Patients with Heart Failure and LVEF <40% on ACEI or ARB and Beta-blocker Therapy", "description": "Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) and a current or prior ejection fraction (EF) <40% who are self-identified Black or African Americans and receiving ACEI or ARB and Beta-blocker therapy who were prescribed a fixed-dose combination of hydralazine and isosorbide dinitrate seen for an office visit in the measurement period in the outpatient setting or at each hospital discharge", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Physicians Genesis Registry, Powered by Premier, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACQR1", "title": "COPD Exacerbation Requiring Hospital Admission: Palliative Care Evaluation", "description": "Patients admitted with 2 or more COPD exacerbations in 12 months or a single admission for COPD with hypercapneic respiratory failure, or being discharged to a SNF or LTACH should receive an evaluation from a palliative care professional, if available", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Acute Care Quality Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACQR2", "title": "COPD Exacerbation: % of patients discharged from inpatient status on Long Acting Beta Agonist (LABA) bronchodilator", "description": "Patients admitted to the hospital with acute COPD exacerbation should be considered for treatment with Long Acting Beta Agonist (LABA) bronchodilator at discharge.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Acute Care Quality Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACQR3", "title": "COPD: Steroids for no more than 5 days in COPD Exacerbation", "description": "Patients should receive no more than 5 days of steroids in treatment for COPD Exacerbation from all sources and routes. Sources may include outpatient, Emergency Department, and Inpatient/Observation treatment. i.e. Full course of steroids not to exceed 7 days.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Acute Care Quality Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACQR4", "title": "CHF Exacerbation Requiring Hospital Admission: Palliative Care Evaluation", "description": "Patients admitted with AHA Class D Heart Failure, and or patients admitted with Congestive Heart Failure (any class) being discharged to a SNF or LTACH should receive an evaluation from a palliative care professional.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Acute Care Quality Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACQR5", "title": "CHF: Document AHA/ACC staging of CHF (A-D)", "description": "The proportion of patients admitted to inpatient status for exacerbation (or new diagnosis) of congestive heart failure that have the AHA and/or NYHA staging documented during their hospitalization", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Acute Care Quality Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACQR6", "title": "POLST Utilization: POLST form reviewed or completed for any patients with limited code status (i.e. any status other than, \"Attempt Resuscitation\" if unresponsive, pulseless and not breathing; and \"Full Treatment\" if patient is pulseless and breathing)", "description": "Understanding a patient's goals of care is a clinical best practice. This measure will track the percentage of patients 65 years of age or older that have a code status discussed, and a POLST completed (or attempted) if there is any limitation in care (i.e. anything but \"full treatment\") selected by the patient or surrogate", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Acute Care Quality Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACQR7", "title": "Sepsis Management: Septic Shock: Repeat Lactate Level Measurement within 6 hours", "description": "Percentage of patients aged 18 years or greater with septic shock and an elevated serum lactate result (>4 mmol/L) with a second serum lactate measurement ordered following the initial elevated result", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Acute Care Quality Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACQR8", "title": "Stroke/TIA: % of patients discharged on antithrombotic therapy", "description": "The percentage of patients aged 18 years and older with diagnosis of (non-embolic) ischemic stroke or transient ischemic attack who were prescribed antithrombotic therapy at discharge", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Acute Care Quality Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACR7", "title": "Gout: Serum Urate Target", "description": "Percentage of patients aged 18 and older with a diagnosis of gout treated with urate-lowering therapy (ULT) for at least 12 months, whose most recent serum urate result is less than 6.8 mg/dL.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "intermediateOutcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Academic Research for Clinical Outcomes (ARCO) - ReportingMD", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD1", "title": "CT Colonography True Positive Rate", "description": "Percentage of exams with a ≥10mm polyp detected by CTC that was with confirmed by colonoscopy (True Positive Rate)", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD15", "title": "Report Turnaround Time: Radiography (modified)", "description": "Mean radiography report turnaround time (RTAT). (Does not include mammography.)\nThis measure has been harmonized with MSN QCDR.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD16", "title": "Report Turnaround Time: Ultrasound (Excluding Breast US)", "description": "Mean Ultrasound report turnaround time (RTAT)\nThis measure has been harmonized with MSN QCDR.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD17", "title": "Report Turnaround Time: MRI", "description": "Mean MRI report turnaround time (RTAT)\nThis measure has been harmonized with MSN QCDR.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD18", "title": "Report Turnaround Time: CT", "description": "Mean CT report turnaround time (RTAT)\nThis measure has been harmonized with MSN QCDR.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD19", "title": "Report Turnaround Time: PET", "description": "Mean PET report turnaround time (RTAT)\nThis measure has been harmonized with MSN QCDR.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD21", "title": "Lung Cancer Screening Cancer Detection Rate (CDR)", "description": "The percentage of screenings of lung cancer that were interpreted as positive (Lung-RADS category 3 or 4) and result in a tissue diagnosis of cancer within 12 months.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD22", "title": "Lung Cancer Screening Positive Predictive Value (PPV)", "description": "The percentage of screenings for lung cancer with abnormal interpretation (Lung-RADS 3 or 4) that result in a tissue diagnosis of cancer within 12 months.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD23", "title": "Lung Cancer Screening Abnormal Interpretation Rate", "description": "The percentage of screening lung cancer interpreted as positive (Lung-RADS Category 3 or 4).", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD25", "title": "Report Turnaround Time: Mammography", "description": "Mean mammography report turnaround time (RTAT).\nThis measure has been harmonized with MSN QCDR.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD26", "title": "Appropriate venous access for hemodialysis", "description": "Percentage of patients undergoing tunneled (long-term) catheter access for hemodialysis via subclavian access as compared to internal jugular access", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD28", "title": "Rate of early peristomal infection following fluoroscopically guided gastrostomy tube placement", "description": "Percentage of patients with peristomal gastrostomy infection no more than14 days following initial tube placement", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD29", "title": "Rate of percutaneous nephrostomy tube replacement within 30 days secondary to dislodgement", "description": "Percentage of percutaneous nephrostomy tube replacement within 30 days following initial placement.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD3", "title": "Screening Mammography Cancer Detection Rate (CDR)", "description": "The fraction of all screening mammograms that are interpreted as positive (abnormal) and have a tissue diagnosis of cancer within 12 months (expressed per 1000 exams, not as a percentage)", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD30", "title": "Rate of Inadequate Percutaneous Image-Guided Biopsy", "description": "The percentage of percutaneous image-guided (US, CT, fluoro) biopsy procedures performed in which sampling was inadequate for diagnosis on the final pathology report.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD31", "title": "Percent of CT Abdomen-pelvis exams with contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level.", "description": "Percent of CT Abdomen-pelvis exams with contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level. Note: Calculated at facility/TIN level and assigned to all NPIs who read CT under that TIN.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD32", "title": "Percent of CT Chest exams without contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level.", "description": "Percent of CT Chest exams without contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level. Note: Calculated at facility/TIN level and assigned to all NPIs who read CT under that TIN.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD33", "title": "Percent of CT Head/Brain exams without contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level", "description": "Percent of CT Head/Brain exams without contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level. Note: Calculated at facility/TIN level and assigned to all NPIs who read CT under that TIN.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD5", "title": "Screening Mammography Abnormal Interpretation Rate (Recall Rate)", "description": "The percentage of screening mammograms interpreted as positive (abnormal)", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD6", "title": "Screening Mammography Positive Predictive Value 2 (PPV2 - Biopsy Recommended)", "description": "The percentage of screening mammograms where biopsy was recommended that have a tissue diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be made on the basis of a diagnostic mammogram that was initiated by findings on the screening", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD7", "title": "Screening Mammography Node Negativity Rate", "description": "The percentage of invasive cancers detected at screening mammography that are node negative", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD8", "title": "Screening Mammography Minimal Cancer Rate", "description": "The percentage of cancers detected at screening mammography that are invasive carcinoma ≤10mm or DCIS", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACS15", "title": "Preoperative Composite", "description": "Percentage of patients who are taken to the operating room for an elective surgical procedure under regional, monitored anesthesia care (MAC), and/or general anesthesia who have been documented for having all three preoperative components addressed during the preoperative phase of care:\n1. The purpose for the recommended procedure AND goals of care discussion has been documented in the medical record.\n2. An identification of significant co-morbid condition(s), if any, documented in the medical record within 30 days of operation date.\n3. An updated history and physical (H&P), documentation that recent laboratory values were reviewed, and\ndocumentation of the site and side of surgery in the medical record within the 24 hours prior to surgery.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Surgeon Specific Registry QCDR Surgical Phases of Care", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACS16", "title": "Preventative Care and Screening: Tobacco Screening and Cessation Intervention", "description": "Percentage of patients age 18 or older who are active tobacco users who receive tobacco screening AND are offered cessation counseling at least 2 months prior to elective surgical procedure in order to delay the procedure until smoking cessation is possibly achieved.", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Surgeon Specific Registry QCDR Surgical Phases of Care", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACS17", "title": "Preoperative Key Medications Review for Anticoagulation Medication", "description": "Percentage of patients who take anticoagulation medication who are taken to the operating room for an elective intervention under regional anesthesia, monitored anesthesia care (MAC), and/or general anesthesia who have a perioperative management plan for anticoagulation medications documented in the medical record.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Surgeon Specific Registry QCDR Surgical Phases of Care", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACS18", "title": "Patient Frailty Evaluation", "description": "Percentage of patients age 65 and older who have been evaluated for frailty prior to an elective operation", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Surgeon Specific Registry QCDR Surgical Phases of Care", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACS19", "title": "Intraoperative Composite", "description": "Percentage of patients age 18 or older who are taken to the operating room for an elective or emergent surgical procedure under regional, MAC, and/or general anesthesia who have been documented for having all two intraoperative components addressed during the intraoperative phase of care:\n1.\tAn intraoperative safety checklist is performed prior to incision that includes the verification of patient's name, the procedure to be performed, laterality, confirmation of site marking, allergies, confirmation of the administration of preoperative antibiotic prophylaxis and VTE prophylaxis if appropriate, anticipated equipment, placement of Bovie pad, correct patient positioning, and display of essential imaging.\n2.\tAn intraoperative surgical debriefing takes place at the end of the case by the surgeon confirming wound classification, correct counts, procedure performed, specimen review, equipment review, postoperative destination and postoperative care plan including plan for perioperative antibiotics, VTE prophylaxis and\nFoley catheter.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Surgeon Specific Registry QCDR Surgical Phases of Care", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACS20", "title": "Optimal Postoperative Communication Plan and Patient Care Coordination Composite", "description": "Percentage of patients, age 18 years or older, who are brought from their home or normal living environment and who are taken to the operating room for an elective surgical intervention under regional anesthesia, MAC, and/or general anesthesia who have been documented for having all four of the following patient care communication and care coordination planning components addressed at the beginning of the postoperative phase of care:\n1.\tA postoperative care plan is established, addressing mobilization, pain management, diet, resumption of preoperative medications, management of drains/catheters/invasive lines, and wound care.\n2.\tA postoperative review of the patient goals of care that were expressed preoperatively and updating those goals of care as appropriate.\n3. A postoperative care coordination with the patient's primary/referring provider regarding the surgery within\n30 days following surgery.\n4.\tA postoperative patient care communication plan with the patient and/or patient's family regarding the surgery and plan for care after discharge.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Surgeon Specific Registry QCDR Surgical Phases of Care", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACS21", "title": "Post-Acute Recovery Composite", "description": "Percentage of patients age 18 or older who are taken to the operating room for an elective intervention under regional, MAC, and/or general anesthesia who have been documented for having all two post-acute components addressed at the beginning of the post-discharge phase of care:\n1.\tA post-discharge review of the patient goals of care that were expressed preoperatively and updating those goals of care as appropriate occurring after discharge up until 30 days following discharge date.\n2.\tA post-discharge follow-up encounter within 30 days updating patient improvements in mobility, pain control, diet, resumption of home medications, wound care, and management of cutaneous/invasive devices (drains,\nIV lines, etc).", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Surgeon Specific Registry QCDR Surgical Phases of Care", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACS22", "title": "Unplanned Reoperation within the 30 Day Postoperative Period", "description": "Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Surgeon Specific Registry QCDR Surgical Phases of Care", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACS23", "title": "Unplanned Hospital Readmission within 30 Days of Principal Procedure", "description": "Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Surgeon Specific Registry QCDR Surgical Phases of Care", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACS24", "title": "Surgical Phases of Care Patient-Reported Outcome Composite Measure", "description": "Composite measure consisting of 12 items intended to measure the constructs of Surgeon Communication Before Surgery, Surgical Goals of Care, Satisfaction with Information, and Postoperative Care Coordination from the patient's perspective. Of these 12 items, 9 originate from the CAHPS Surgical Care Survey (S-CAHPS). Specifically, these 9 items are questions 3, 9, 11, 17, 26, 27, 31, 33, and 34 from the original S-CAHPS survey. Three (3) additional items are included to appropriately measure Goals of Care; these questions ask whether the surgeon discussed what the patient hoped to gain from surgery, whether the surgeon discussed how surgery would affect their daily activities, and what life might look like for the patient in the long-term. Please see the attachment for all 12 items in full.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "patientEngagementExperience", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Surgeon Specific Registry QCDR Surgical Phases of Care", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACS25", "title": "Surgical Site Infection (SSI)", "description": "Percentage of patients aged 18 years and older who had a surgical site infection (SSI).", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Surgeon Specific Registry QCDR Surgical Phases of Care", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACSTRAUMA1", "title": "Trauma Initial Assessment Composite", "description": "Percentage of blunt multisystem trauma patients having the following components documented upon presentation to the emergency department (ED) within 30 minutes of arrival:\n1. Glasgow Coma Scale (GSC) score\n2. Temperature", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Surgeon Specific Registry QCDR Trauma Measures", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACSTRAUMA2", "title": "Mortality Rate Following Blunt Traumatic Injury to the Chest and/or Abdomen", "description": "In-hospital mortality rate for patients with severe blunt injury to the abdomen and/or chest (Abbreviated Injury Score [AIS] ≥ 3).", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Surgeon Specific Registry QCDR Trauma Measures", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACSTRAUMA3", "title": "Mortality Rate Following Penetrating Traumatic Injury to the Chest and/or Abdomen", "description": "In-hospital mortality rate for patients with severe penetrating injury to the abdomen and/or chest (Abbreviated Injury Score [AIS] ≥ 3).", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Surgeon Specific Registry QCDR Trauma Measures", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACSTRAUMA4", "title": "Splenic Salvage Rate", "description": "Percentage of patients with a spleen injury (spleen AIS ≥ 2 and < 5) that do not undergo a splenectomy.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Surgeon Specific Registry QCDR Trauma Measures", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACSTRAUMA5", "title": "Optimal Timing of Surgical or Procedural Intervention for Hemorrhage in Trauma", "description": "Percentage of patients presenting with traumatic hemorrhagic shock who undergo an operative or procedural intervention for hemorrhage control within 4 hours.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Surgeon Specific Registry QCDR Trauma Measures", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACSTRAUMA6", "title": "Optimal Ratio of Blood Product Transfusion", "description": "Percentage of patients presenting with traumatic hemorrhagic shock who receive plasma and packed red blood cells (pRBC’s) in a ratio higher or equal to 1 unit of plasma for every 2 units of pRBCs over the first four hours after arrival to the emergency department.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Surgeon Specific Registry QCDR Trauma Measures", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACSTRAUMA7", "title": "Timely Initiation of VTE Prophylaxis in Trauma Patients", "description": "Percentage of seriously injured patients with pharmacologic venous thromboembolism (VTE) prophylaxis initiated within 48 hours of admission.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Surgeon Specific Registry QCDR Trauma Measures", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AHSQC1", "title": "Ventral Hernia Repair: Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period", "description": "Percentage of patients aged 18 years and older who have undergone ventral hernia repair who had a surgical site occurrence requiring procedural intervention within the 30 day postoperative period. Surgical site occurrences include any surgical site infections (superficial, deep, organ space) or any of the following: wound cellulitis, non-healing incisional wound, fascial disruption, skin or soft tissue ischemia, skin or soft tissue necrosis, wound serous drainage, wound purulent drainage, chronic sinus drainage, localized stab wound infection, stitch abscess, seroma, infected seroma, hematoma, infected hematoma, exposed biologic mesh, exposed synthetic mesh, contaminated biologic mesh, contaminated synthetic mesh, infected biologic mesh, infected synthetic mesh, mucocutaneous anastomosis disruption, enterocutaneous fistula). Procedural interventions include any of the following: wound opening, wound debridement, suture excision, percutaneous drainage, partial mesh removal, complete mesh removal.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "AHSQC", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AHSQC2", "title": "Unplanned Hospital Readmission or Observation Visit within the 30 Day Postoperative Period", "description": "Percentage of patients aged 18 years and older who had any unplanned hospital readmission or 23 hour observation visit within the 30 day postoperative period", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "AHSQC", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AHSQC6", "title": "Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period", "description": "Percentage of patients aged 18 years and older who have undergone abdominal wall reconstruction defined as ventral hernia repair with myofascial release (abdominal wall fascial layer separated from muscular layer) who had a surgical site occurrence requiring procedural intervention within the 30 day postoperative period. Surgical site occurrences include any surgical site infections (superficial, deep, organ space) or any of the following: wound cellulitis, non-healing incisional wound, fascial disruption, skin or soft tissue ischemia, skin or soft tissue necrosis, wound serous drainage, wound purulent drainage, chronic sinus drainage, localized stab wound infection, stitch abscess, seroma, infected seroma, hematoma, infected hematoma, exposed biologic mesh, exposed synthetic mesh, contaminated biologic mesh, contaminated synthetic mesh, infected biologic mesh, infected synthetic mesh, mucocutaneous anastomosis disruption, enterocutaneous fistula). Procedural interventions include any of the following: wound opening, wound debridement, suture excision, percutaneous drainage, partial mesh removal, complete mesh removal.\n\nThis measure is reported as three performance rates stratified by hernia width:\nRate 1: Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Any hernia width (overall rate)\nRate 2: Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of ≤10cm\nRate 3: Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of >10cm", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "AHSQC", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "overall", "description": "Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Any hernia width (overall rate)" }, { "name": "<=10cm", "description": "Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of ≤10cm" }, { "name": ">10cm", "description": "Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of >10cm" } ], "submissionMethods": [ "registry" ] }, { "measureId": "AHSQC8", "title": "Ventral Hernia Repair: Biologic Mesh Prosthesis Use in Low Risk Patients", "description": "Percentage of patients aged 18 years and older who have undergone low risk (elective, class I wound, no active skin infection, no stoma present) ventral hernia repair using biologic mesh placement", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "AHSQC", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AHSQC9", "title": "Ventral Hernia Repair: Pain and Functional Status Assessment", "description": "Percentage of patients aged 18 years and older who have undergone ventral hernia repair with completed preoperative (baseline) and at least one follow-up patient reported pain and functional status assessment (patient reported outcome). These patient reported outcomes can be completed with an in-person clinical visit, phone call, smartphone, or email.\n\nThis measure is reported as two performance rates:\nRate 1: Ventral Hernia Repair: Pain and Functional Status Assessment-Overall completion rate\nRate 2: Ventral Hernia Repair: Pain and Functional Status Assessment-Email engagement completion rate", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AHSQC", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "overall", "description": "Ventral Hernia Repair: Pain and Functional Status Assessment-Overall completion rate" }, { "name": "email", "description": "Ventral Hernia Repair: Pain and Functional Status Assessment-Email engagement completion rate" } ], "submissionMethods": [ "registry" ] }, { "measureId": "AJRR1", "title": "Hip Arthroplasty: Postoperative Complications within 90 Days Following the Procedure", "description": "Percentage of patients undergoing an elective primary total hip arthroplasty who did not have a secondary procedure on the operative hip for any of the following reasons: periprosthetic fracture, dislocation, mechanical failure of the implant, irrigation/debridement of deep infection or a debridement of a superficial infection or hematoma within 90 days following the procedure.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Orthopaedic Quality Resource Center, Powered by Premier, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AJRR3", "title": "Hip Arthroplasty: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy", "description": "Percentage of patients undergoing a hip arthroplasty with documented shared decision-making including discussion of conservative (non-surgical) therapy (e.g. NSAIDs, analgesics, weight loss, exercise, injections) prior to the procedure.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Orthopaedic Quality Resource Center, Powered by Premier, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AJRR4", "title": "Hip Arthroplasty: Venous Thromboembolic and Cardiovascular Risk Evaluation", "description": "Percentage of patients undergoing a hip arthroplasty who are evaluated for the presence or absence of cardiovascular risk factors within 30 days prior to the procedure (e.g. history of deep venous thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI), arrhythmia, and stroke).", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Orthopaedic Quality Resource Center, Powered by Premier, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "APMA1", "title": "Comprehensive Diabetic Foot Examination", "description": "Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus that had a comprehensive diabetic foot examination with risk categorization based on exam findings during one or more office visits within 12 months", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "APMA Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI18", "title": "Coronary Artery Bypass Graft (CABG): Prolonged Intubation – Inverse Measure", "description": "Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI41", "title": "Coronary Artery Bypass Graft (CABG): Stroke – Inverse Measure", "description": "Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have a postoperative stroke that did not resolve within 24 hours", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI42", "title": "Coronary Artery Bypass Graft (CABG): Post-Operative Renal Failure – Inverse Measure", "description": "Percentage of patients aged 18 years and older undergoing isolated CABG surgery who develop postoperative renal failure or require dialysis", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI48", "title": "Patient-Reported Experience with Anesthesia", "description": "Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care and who reported a positive experience.\n\nThis measure will consist of two performance rates:\n\nRate 1: AQIXXa - Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care\nRate 2: AQIXXb - Percentage of patients, aged 18 and older, who completed a survey on their patient experience and satisfaction with anesthesia care who report a positive experience with anesthesia care\n\nNOTE: The measure requires that a valid survey, as defined in the numerator, be sent to patients between discharge from the facility and within 30 days of facility discharge. To report AQI 48b, a minimum number of 20 surveys with the mandatory question completed must be reported.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "surveyed", "description": "AQIXXa - Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care" }, { "name": "overall", "description": "AQIXXb - Percentage of patients, aged 18 and older, who completed a survey on their patient experience and satisfaction with anesthesia care who report a positive experience with anesthesia care\n\nNOTE: The measure requires that a valid survey, as defined in the numerator, be sent to patients between discharge from the facility and within 30 days of facility discharge. To report AQI 48b, a minimum number of 20 surveys with the mandatory question completed must be reported." } ], "submissionMethods": [ "registry" ] }, { "measureId": "AQI49", "title": "Adherence to Blood Conservation Guidelines for Cardiac Operations using Cardiopulmonary Bypass (CPB) – Composite", "description": "Percentage of patients, aged 18 years and older, who undergo a cardiac operation using cardiopulmonary bypass for whom selected blood conservation strategies were used.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI50", "title": "Application of Lung-Protective Ventilation during General Anesthesia", "description": "Percentage of patients, aged 12 years and older, who undergo general anesthesia care that includes an endotracheal tube who had a median exhaled tidal volume less than 10 mL/kg of ideal body weight during positive pressure ventilation (PPV)", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "intermediateOutcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI51", "title": "Assessment of Patients for Obstructive Sleep Apnea", "description": "Percentage of patients, aged 18 years and older, who underwent an elective procedure under anesthesia who were screened preoperatively for Obstructive Sleep Apnea (OSA) using a standardized tool prior to the procedure", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI53", "title": "Documentation of Anticoagulant and Antiplatelet Medications when Performing Neuraxial Anesthesia/Analgesia or Interventional Pain Procedures", "description": "Percentage of patients, regardless of age, taking anticoagulant and/or antiplatelet medications who undergo an interventional pain procedure or other surgical or therapeutic procedure under neuraxial anesthesia or analgesia where the name, date last taken, and, if applicable, time last taken of anticoagulant and/or antiplatelet medications prior to administration of anesthesia are documented", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI54", "title": "Use of Pencil-Point Needle for Spinal Anesthesia", "description": "Percentage of patients, regardless of age, who undergo an obstetric procedure using spinal anesthesia where a pencil-point needle is used to access the intrathecal space", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI55", "title": "Team-Based Implementation of a Care-and-Communication Bundle for ICU Patients", "description": "Percentage of patients, regardless of age, who are admitted to an intensive care unit (ICU) for ≥48 hours and who received critical care services who have documentation by managing physician of 1) attempted or actual identification of a surrogate decision maker, 2) an advance directive, and 3) the patient’s preference for cardiopulmonary resuscitation, within 48 hours of ICU admission", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI56", "title": "Use of Neuraxial Techniques and/or Peripheral Nerve Blocks for Total Knee Arthroplasty (TKA)", "description": "Percentage of patients, regardless of age, that undergo total knee arthroplasty for whom neuraxial anesthesia and/or a peripheral nerve block is performed.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI57", "title": "Safe Opioid Prescribing Practices", "description": "Percentage of patients, aged 18 years and older, prescribed opioid medications for longer than six weeks’ duration for whom ALL of the following opioid prescribing best practices are followed:\n\n1. Chemical dependency screening (includes laboratory testing and/or questionnaire) within the immediate 6 months prior to the encounter\n2. Co-prescription of naloxone or documented discussion regarding offer of Naloxone co-prescription, if prescription is ≥50 MME/day\n3. Non co-prescription of benzodiazepine medications by prescribing pain physician and documentation of a discussion with patient regarding risks of concomitant use of benzodiazepine and opioid medications.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI58", "title": "Infection Control Practices for Open Interventional Pain Procedures", "description": "Percentage of patients, regardless of age, that undergo an open interventional pain procedure for whom ALL of the following infection control best practices are followed by anesthesiologist(s) and scrub technologist(s), in addition to standard sterile technique:\n1. Double gloving (two pairs of sterile gloves are worn)\n2. Chlorhexidine with alcohol used\n3. Weight-based preoperative antibiotic dosing and, if indicated by procedure duration, weight-based re-dosing\n4. Administration of pre-operative antibiotics within 1 hour, or 2 hours for vancomycin, prior to surgical incision", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI59", "title": "Multimodal Pain Management", "description": "Percentage of patients, regardless of age, undergoing selected elective surgical procedures that were managed with multimodal pain medicine.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI60", "title": "New Corneal Injury Not Diagnosed Prior to Discharge", "description": "Percentage of patients, aged 18 years or older, who undergo anesthesia care and did not have a new diagnosis of corneal injury prior to facility discharge.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA12", "title": "Benign Prostate Hyperplasia: IPSS improvement after diagnosis", "description": "Percentage of patients with NEW diagnosis of clinically significant BPH who had IPSS (international prostate symptoms score) or AUASS (American urological association symptom score) improvement by ≥20%.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA13", "title": "Stress Urinary Incontinence (SUI): Revision surgery within 12 months of incontinence procedure", "description": "Percentage of women who undergo surgery for stress incontinence who require revision surgery within 12 months", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA14", "title": "Stones: Repeat Shock Wave Lithotripsy (SWL) within 6 months of treatment", "description": "Percentage of patients who underwent endoscopic procedures following SWL", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA15", "title": "Stones: Urinalysis documented 30 days before surgical stone procedures", "description": "Percentage of patients with a documented urinalysis 30 days before surgical stone procedures", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA16", "title": "Non-Muscle Invasive Bladder Cancer: Repeat Transurethral Resection of Bladder Tumor (TURBT) for T1 disease", "description": "Percentage of patients with T1 disease, that had a second TURBT within 6 weeks of the initial TURBT", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA17", "title": "Non-Muscle Invasive Bladder Cancer: Initiation of BCG 3 months of diagnosis of high-grade T1 bladder cancer and/or CIS", "description": "Percentage of patients who initiate BCG treatment within 3 months of diagnosis of high-grade T1 bladder cancer and/or CIS", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA18", "title": "Non-Muscle Invasive Bladder Cancer: Early surveillance cystoscopy within 4 months of initial diagnosis", "description": "Percentage of patients who receive surveillance cystoscopy within 4 months of TURBT for bladder cancer", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA19", "title": "Diagnosis of Type of Azoospermia and Diagnostic Testing for Obstructive Azoospermia", "description": "Percentage of patients who had minimum necessary concepts discussed as part of diagnosis of azoospermia alone, to determine possibility of obstructive versus non-obstructive azoospermia and underwent diagnostic testing for obstructive azoospermia", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA20", "title": "Genetic Testing of the Azoospermic Male", "description": "Percentage of patients with non-obstructive azoospermia due to primary testis failure who were offered genetic testing", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA21", "title": "Appropriate Management of Obstructive Azoospermia", "description": "Percentage of obstructive azoospermia patients managed appropriately", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA22", "title": "Bone imaging and soft tissue imaging at the time of diagnosis of metastatic CRPC", "description": "Percentage of patients who receive bone imaging and soft tissue imaging at the time of diagnosis of metastatic CRPC", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA23", "title": "Blood work for patients receiving abiraterone", "description": "Percentage of patients receiving abiraterone who receive monthly blood work and serum transaminases (ALT and AST) and bilirubin levels prior to starting treatment and every two weeks for the first three months of treatment and monthly thereafter", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA24", "title": "Testosterone and PSA levels checked for CRPC patients", "description": "Percentage of patients on hormonal therapy who have their testosterone and PSA levels checked before starting treatment for CRPC", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA25", "title": "Use of Prednisone for CRPC patients on abiraterone", "description": "Percentage of patients who are receiving abiraterone who are also receiving prednisone.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA26", "title": "Benign Prostate Hyperplasia Care: Benign Prostate Hyperplasia", "description": "Percentage of patients with new diagnosis of BPH who had a creatinine lab order placed or had a CT abdomen, MRI abdomen, ultrasound abdomen ordered or performed.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA27", "title": "Appropriate Testing for Vasectomy Patients", "description": "Percentage of patients where a Post Vasectomy Semen Analysis (PVSA) was ordered and confirmed sterility within 6 months of undergoing a vasectomy", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA28", "title": "Hypogonadism: Testosterone and hematocrit within 6 months of starting testosterone replacement", "description": "Percentage of patients with hypogonadism, starting testosterone medication (any formulation of testosterone) or rec’d testosterone injection in clinic have testosterone level ordered within 6 months of first testosterone Rx or injection", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA29", "title": "Prostate Cancer: Patient Report of Urinary function after treatment", "description": "Percentage of patients who had a reported urinary function score at 12 months after treatment that is within 80% of the reported urinary function score at baseline (before treatment)", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA3", "title": "Cryptorchidism: Inappropriate use of scrotal/groin ultrasound on boys", "description": "Percentage of patients (boys) =< 18 yrs. of age newly diagnosed with undescended testis or retractile testis with an order for ultrasound (scrotal or groin) placed", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA30", "title": "Prostate Cancer: Patient Report of Sexual function after treatment", "description": "Percentage of patients who had a reported sexual function score at 24 months after treatment that is within 60% of the reported sexual function score at baseline (before treatment)", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA8", "title": "Hospital admissions/complications within 30 days of TRUS Biopsy", "description": "Percentage of patients who had TRUS biopsy performed who had ≥24h after the biopsy): infection, hematuria, new antibiotic Rx after biopsy, or inpatient consultation within 30 days", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ARCO10", "title": "Risk Standardized Mortality Rate within 30 days following Trauma Operation", "description": "Percentage of patients evaluated as part of a trauma activation or trauma consultation who are taken to the operating room for an abdominal operation who expired prior to hospital discharge.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Academic Research for Clinical Outcomes (ARCO) - ReportingMD", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ARCO11", "title": "Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients who Received Head CT or MRI Scan Interpretation within 45 minutes of ED Arrival", "description": "This measure calculates the percentage of acute ischemic stroke or hemorrhagic stroke patients who arrive at the ED within two hours of the onset of symptoms and have a head computed tomography (CT) or magnetic resonance imaging (MRI) scan interpreted within 45 minutes of ED arrival. This measure is included in the CMS Hospital Outpatient Quality Reporting (HOQR) system measure portfolio.\n\nHOQR is a quality data-reporting program, implemented by CMS for outpatient hospital services. Under this program, hospitals report data using standardized measures of care to receive the full annual update to their Outpatient Prospective Payment System (OPPS) payment rate, effective for payments beginning in calendar year 2009. To meet HOQR Program requirements and receive the full Annual Payment Update (APU) under the OPPS, hospitals must meet administrative, data collection and submission, and data validation requirements. Participating hospitals agree that they will allow CMS to publicly report data for the quality measures (as stated in the current OPPS Final Rule). In the context of this quality measure reporting program, NQF #0661 is referred to as ´OP-23.´", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Academic Research for Clinical Outcomes (ARCO) - ReportingMD", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ARCO12", "title": "STK-01: Venous Thromboembolism (VTE) Prophylaxis", "description": "This measure captures the proportion of ischemic or hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given on the day of or the day after hospital admission. This measure is a part of a set of eight nationally implemented measures that address stroke care (STK-2: Discharged on Antithrombotic Therapy, STK-3: Anticoagulation Therapy for Atrial Fibrillation/Flutter, STK-4: Thrombolytic Therapy, STK-5: Antithrombotic Therapy By End of Hospital Day 2, STK-6 Discharged on Statin Medication, STK-8: Stroke Education, and STK-10: Assessed for Rehabilitation) that are used in The Joint Commission’s hospital accreditation and Disease-Specific Care certification programs.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Academic Research for Clinical Outcomes (ARCO) - ReportingMD", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ARCO13", "title": "STK 02: Ischemic stroke patients management -", "description": "This measure will be calculated with 3 performance rates:\nRate 1: The percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge;\nRate 2: The percent of ischemic stroke patients who had antithrombotic therapy administered by end of hospital day two;\nRate 3: The percent of ischemic stroke patients with an LDL greater than or equal to 100 mg/dL, OR LDL not measured, OR who were on a lipid-lowering medication prior to hospital arrival who were prescribed statin medication at hospital discharge", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Academic Research for Clinical Outcomes (ARCO) - ReportingMD", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "sumNumerators", "strata": [ { "name": "antithrombotic", "description": "The percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge;" }, { "name": "antithrombotic2", "description": "The percent of ischemic stroke patients who had antithrombotic therapy administered by end of hospital day two;" }, { "name": "LDL", "description": "The percent of ischemic stroke patients with an LDL greater than or equal to 100 mg/dL, OR LDL not measured, OR who were on a lipid-lowering medication prior to hospital arrival who were prescribed statin medication at hospital discharge" } ], "submissionMethods": [ "registry" ] }, { "measureId": "ARCO15", "title": "Diabetes: Nutritional, Weight Loss Counseling, Reduction of Sedentary Behavior", "description": "Percentage of diabetic patients receiving nutritional counseling", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Academic Research for Clinical Outcomes (ARCO) - ReportingMD", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ARCO16", "title": "Dyspnea or Heart Failure: Use of BNP or NT- pro BNP screening", "description": "Percent of patients with dyspnea or heart failure that have received BNP or NT- pro BNP screening as a tool to support clinical decision making in regards to the diagnosis or disease severity of heart failure, especially in the setting of clinical uncertainty.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Academic Research for Clinical Outcomes (ARCO) - ReportingMD", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ARCO17", "title": "Heart Failure: Use of Aldosterone Antagonists and Diuretics for Symptom Control", "description": "Percent of heart failure patients with reduced ejection fraction < 40% on aldosterone antagonists. Aldosterone receptor antagonists (or mineralocorticoid receptor antagonists) are recommended in patients with NYHA class II–IV HF and who have LVEF of 40% or less, unless contraindicated, to reduce morbidity and mortality.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Academic Research for Clinical Outcomes (ARCO) - ReportingMD", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ARCO18", "title": "Heart Failure: Counseling on Self-care, Including Monitoring Blood Pressure, Weight, Sodium Intake, and Physical Activity", "description": "Percentage of Heart Failure patients receiving counseling on self-care including monitoring of blood pressure, weight, sodium intake, and physical activity", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Academic Research for Clinical Outcomes (ARCO) - ReportingMD", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ARCO19", "title": "Promoting self-care for prevention and management of chronic conditions", "description": "Percentage of patients, regardless of age, with a diagnosis of Hypertension, Heart Failure, Stroke, Atrial Fibrillation, Coronary Heart Disease, Peripheral Artery Disease, obesity, hyperlipidemia, tobacco dependence, depression who were counseled regarding the use of self-care for prevention and management of chronic conditions, within a 12 month period", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Academic Research for Clinical Outcomes (ARCO) - ReportingMD", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ARCO20", "title": "Percentage of patients using self-monitoring with mobile technology or eHealth solutions to manage their diabetes, hypertension, sodium intake, nutritional status, physical activity, tobacco use, alcohol use, and sedentary behaviors", "description": "Percentage of patients, regardless of age, with a diagnosis of dysmetabolic syndrome, heart failure, obesity, tobacco use, hypertension (all stages), diabetes (all types), coronary artery disease, and dyslipidemia, hyperlipidemia, and depression who use self-monitoring with or without mobile technology during the 12 month reporting period to manage their diabetes, hypertension, sodium intake, nutritional status, physical activity, tobacco use, alcohol use, and sedentary behaviors.", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Academic Research for Clinical Outcomes (ARCO) - ReportingMD", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ARCO3", "title": "Antipsychotic Use in Persons with Dementia", "description": "The percentage of individuals 65 years of age and older with dementia who are receiving an antipsychotic medication without evidence of a psychotic disorder or related condition.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Academic Research for Clinical Outcomes (ARCO) - ReportingMD", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASBS1", "title": "Surgeon assessment for hereditary cause of breast cancer", "description": "Percent of newly diagnosed invasive and ductal carcinoma in situ (DCIS) breast cancer patients (Stage 0 - Stage 4) seen by surgeon that undergo risk assessment for a hereditary cause of breast cancer. Patients with Lobular Carcinoma in situ (LCIS) are excluded from this Quality Measure.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "The American Society of Breast Surgeons Mastery of Breast Surgery Program", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASBS10", "title": "Management of the axilla in breast cancer patients undergoing breast conserving surgery with a positive sentinel node biopsy", "description": "Percent of Z0011 eligible breast cancer patients who do not undergo completion axillary dissection", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "The American Society of Breast Surgeons Mastery of Breast Surgery Program", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASBS12", "title": "Return to the operating room for re-excision of previous microscopically negative margins in invasive breast cancer patients undergoing breast conserving therapy", "description": "The percent of patients with a known diagnosis of invasive breast cancer undergoing lumpectomy (partial mastectomy) breast cancer operations who obtained microscopically negative margins at the first operation and did not return for additional operations in order to excise additional tissue for margin clearance.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "The American Society of Breast Surgeons Mastery of Breast Surgery Program", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASBS13", "title": "Sentinel Node Biopsy for Patients with Ductal Carcinoma in Situ Alone", "description": "The percent of patients with a known diagnosis of ductal carcinoma in situ alone on core needle biopsy undergoing breast cancer operations who did not undergo sentinel node biopsy in the setting of breast conserving therapy.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "The American Society of Breast Surgeons Mastery of Breast Surgery Program", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASBS14", "title": "Recommendation of Neoadjuvant Chemotherapy for Her2Neu positive invasive breast cancers that are >2.0cm in size and/or have needle biopsy proven axillary metastases.", "description": "The percent of patients with a known diagnosis of human epidermal growth factor receptor 2 (Her2Neu) positive invasive breast cancer undergoing breast cancer operations who were advised to undergo neoadjuvant chemotherapy prior to surgical intervention.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "The American Society of Breast Surgeons Mastery of Breast Surgery Program", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASBS7", "title": "Unplanned 30 day re-operation after mastectomy", "description": "Percent of patients undergoing mastectomy who do not require an unplanned\nsecondary breast or axillary operation within 30 days of the initial procedure.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "The American Society of Breast Surgeons Mastery of Breast Surgery Program", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASNC1", "title": "Cardiac Stress Nuclear Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients", "description": "Percentage of stress nuclear Myocardial Perfusion Imaging (MPI) studies performed on low-risk surgery patients 18 years or older for preoperative evaluation.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASNC19", "title": "Imaging Protocols for SPECT and PET MPI studies - Use of stress only protocol", "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) and Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies performed where the imaging protocol used was stress only.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASNC2", "title": "Cardiac Stress Nuclear Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)", "description": "Percentage of stress nuclear Myocardial Perfusion Imaging (MPI) studies performed on patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASNC20", "title": "SPECT-MPI studies performed without the use of thallium", "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies performed without the use of thallium.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASNC21", "title": "SPECT-MPI study appropriate imaging protocol selection for morbidly obese patients", "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies performed on morbidly obese patients where the Imaging Protocol included two days.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASNC22", "title": "SPECT and PET MPI studies reporting Left Ventricular Ejection Fraction", "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) and Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies where the Left Ventricle Ejection Fraction was calculated and included in the report.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASNC23", "title": "SPECT-MPI study clinical utilization of Attenuation Correction image acquisition", "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies using Attenuation Correction.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASNC24", "title": "SPECT-MPI study utilization of exercise as a stressor", "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies using a Stress Test Type that includes exercise.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASNC25", "title": "SPECT-MPI study adequate exercise testing performed", "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies performed where the stress heart rate >= 85% of maximum heart rate and three or more minutes of exercise.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASNC26", "title": "SPECT and PET MPI studies meeting appropriate use criteria", "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) and Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies performed that are appropriate.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASNC27", "title": "SPECT and PET MPI studies not Equivocal", "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) and Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies performed that are not equivocal.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASNC28", "title": "Effective dose less than or equal to 9 millisieverts as per ASNC guideline recommendations", "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies where patient received 9 or less millisieverts of radiation as per ASNC guideline recommendations.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASNC29", "title": "SPECT and PET MPI study documentation of stress perfusion defects", "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) and Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies performed that were abnormal and contained perfusion defects documentation including location, severity, size and type.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASNC3", "title": "Cardiac Stress Nuclear Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients", "description": "Percentage of stress nuclear Myocardial Perfusion Imaging (MPI) studies performed on asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASNC30", "title": "Transthoracic Echo (TTE) studies meeting appropriate use criteria", "description": "Percentage of appropriate Transthoracic Echo (TTE) studies", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASNC31", "title": "Transthoracic Echo (TTE) studies reporting pulmonary artery pressures, 100% views, contrast use", "description": "Percentage of Transthoracic Echo (TTE) studies reporting 100% obtainment of required views, OR utilizing contrast, OR reporting pulmonary artery pressures.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASPIRE18", "title": "Avoiding myocardial Injury", "description": "Percentage of cases with elevated postoperative troponin levels (Troponin 1 > 0.6) or documentation of perioperative myocardial injury.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Multicenter Perioperative Outcomes Group (MPOG)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASPIRE19", "title": "Avoiding acute kidney injury", "description": "Percentage of cases that the baseline creatinine does not increase more than 1.5 times within 7 days post-op or the baseline creatinine level does not increase by ≥ 0.3 mg/dL within 48 hours post-operatively.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Multicenter Perioperative Outcomes Group (MPOG)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASPIRE2", "title": "Train of Four Monitor Documented After Last Dose of Non-depolarizing Neuromuscular Blocker", "description": "Percentage of the patients with documentation of a Train of Four count or acceleromyography result after the last dose of a non-depolarizing muscle relaxant", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Multicenter Perioperative Outcomes Group (MPOG)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASPIRE6", "title": "Application of Lung-Protective Ventilation during General Anesthesia", "description": "Percentage of patients, aged 18 and older, who undergo general anesthesia care that includes an endotracheal tube who had a median exhaled tidal volume less than or equal to 10mL/kg of predicted-body-weight (PBW) during positive pressure ventilation (PPV).", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "intermediateOutcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Multicenter Perioperative Outcomes Group (MPOG)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASPS10", "title": "Patient Satisfaction with Information Provided during Breast Reconstruction", "description": "Percentage of patients aged 18 years and older who had breast reconstruction who reported a score of 65 or higher on the BREAST-Q Satisfaction with Information scale, within 120 days of the procedure.\n\nThis measure is reported as three rates stratified by procedure:\n•Reporting Criteria 1: Implant Breast Reconstruction Procedures\n•Reporting Criteria 2: Autologous Breast Reconstruction Procedures\n•Total Rate: All breast reconstruction Procedures", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ASPS TOPS-QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASPS11", "title": "Operative Time for Autologous Breast Reconstruction", "description": "Percentage of female patients aged 18 years and older who had unilateral breast reconstruction via autologous free tissue reconstruction with or without a tissue expander or implant whose operative time* did not exceed 10 hours.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ASPS TOPS-QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASPS12", "title": "Unplanned hospital admission after panniculectomy", "description": "Percentage of patients aged 18 years and older who undergo primary panniculectomy who have an unplanned hospital admission within 30 days of initial procedure", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ASPS TOPS-QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASPS13", "title": "Wound disruption rate after primary panniculectomy in patients with BMI > or = to 35", "description": "Percentage of patients aged 18 years and older with a BMI > or = to 35 who undergo primary panniculectomy who develop moderate or severe wound disruption within 30 days of initial procedure", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ASPS TOPS-QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASPS14", "title": "Wound disruption rate after primary panniculectomy in patients with BMI < 35", "description": "Percentage of patients aged 18 years and older with a BMI < 35 who undergo primary panniculectomy who develop moderate or severe wound disruption within 30 days of initial procedure", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ASPS TOPS-QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASPS15", "title": "Seroma rate after primary panniculectomy", "description": "Percentage of patients aged 18 years and older who undergo primary panniculectomy who develop clinically significant seroma requiring operative placement of a drain within 30 days of initial procedure.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ASPS TOPS-QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASPS5", "title": "Breast Reconstruction: Return to OR", "description": "Percentage of female patients aged 18 years and older who had breast reconstruction who have an unplanned second operation on the reconstruction site within 60 days of the primary breast reconstruction procedure.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "intermediateOutcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ASPS TOPS-QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASPS6", "title": "Breast Reconstruction: Flap Loss", "description": "All female patients aged 18 years and older who had breast reconstruction via autologous reconstruction (not including latissimus flap) with or without a tissue expander or implant", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ASPS TOPS-QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASPS7", "title": "Rate of Blood Transfusion for Patients Undergoing Autologous Breast Reconstruction", "description": "Percentage of female patients aged 18 years and older who had breast reconstruction via autologous reconstruction (not including latissimus flap) with or without a tissue expander or implant who received blood or blood product transfusion during hospitalization.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ASPS TOPS-QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASPS8", "title": "Coordination of Care for Patients Undergoing Breast Reconstruction", "description": "Percentage of female patients aged 18 years and older with genetic susceptibility to malignant neoplasm of the breast, current diagnosis or history of breast cancer AND breast reconstruction with or without a tissue expander or implant who had documentation of coordinated care* prior to their procedure", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ASPS TOPS-QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASPS9", "title": "Length of Stay Following Autologous Breast Reconstruction", "description": "Percentage of female patients aged 18 years and older who had breast reconstruction via autologous reconstruction (not including latissimus flap) with or without a tissue expander or implant who were discharged from the hospital by the end of post-operative day 5", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "intermediateOutcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ASPS TOPS-QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AUGS1", "title": "Complete assessment and evaluation of patient’s pelvic organ prolapse prior to surgical repair", "description": "Percentage of patients undergoing surgical repair of pelvic organ prolapse who have a documented, complete characterization of pelvic organ prolapse in each vaginal compartment using one of the accepted, objective measurement systems (POP‐Q or Baden/Walker).", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AQUIRE Quality Improvement Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AUGS10", "title": "Documentation of offering a preoperative pessary for Pelvic Organ Prolapse", "description": "The percentage of patients who have been offered a pessary for the treatment of pelvic organ prolapse prior to surgical intervention", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AQUIRE Quality Improvement Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AUGS11", "title": "Documentation that a trial of conservative management was offered prior to use of procedure based therapy for urgency urinary incontinence", "description": "The percentage of patients offered conservative measures for the management of urgency urinary incontinence prior to use of procedure based therapy.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AQUIRE Quality Improvement Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AUGS3", "title": "Preoperative assessment of sexual function prior to pelvic organ prolapse repair", "description": "Percentage of patients having a documented assessment of sexual function prior to surgery for pelvic organ prolapse.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AQUIRE Quality Improvement Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AUGS4", "title": "Performing an intraoperative rectal examination at the time of prolapse repair", "description": "Percentage of patients having a documented rectal examination at the time of surgery for repair of apical and posterior pelvic organ prolapse.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AQUIRE Quality Improvement Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AUGS5", "title": "Performing vaginal apical suspension at the time of hysterectomy to address pelvic organ prolapse", "description": "Percentage of patients undergoing hysterectomy for the indication of pelvic organ prolapse in which a concomitant vaginal apical suspension (i.e. uterosacral, iliococygeus, sacrospinous or sacral colpopexy, or enterocele repair) is performed.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AQUIRE Quality Improvement Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AUGS6", "title": "Route of Hysterectomy", "description": "Percentage of patients who underwent vaginal hysterectomy.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AQUIRE Quality Improvement Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AUGS7", "title": "Documentation that conservative management was offered prior to fecal incontinence surgery or procedures", "description": "The percentage of patients offered non-surgical treatment options for fecal incontinence prior to surgery.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AQUIRE Quality Improvement Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AUGS8", "title": "Documentation of weight loss counseling prior to surgery for stress urinary incontinence procedures for obese women", "description": "Percentage of obese patients having documented weight loss counseling prior to undergoing anti-urinary incontinence procedures.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AQUIRE Quality Improvement Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AUGS9", "title": "Over-utilization of synthetic mesh in the posterior compartment", "description": "Percentage of patients undergoing vaginal surgery for pelvic organ prolapse involving the posterior compartment where a synthetic mesh augment is utilized.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "AQUIRE Quality Improvement Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "BIVARUS27", "title": "Patient Reported Comprehensive Assessment of Safety", "description": "A composite score on this measure is derived from responses on 5 items (each item scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR composite measure. Note: Limiting the composite measure score to the highest response category\nprovides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level.\n Items:\n Bivarus 1: Hand Sanitation Performed By My Provider\n Bivarus 2: Medication Reconciliation Performed At My Visit\n Bivarus 3: Practice Asked Me About Allergies\n Bivarus 5: Practice Explained Medications Before Giving Them\n Bivarus 10: Overall Assessment Of Safety", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "patientEngagementExperience", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Bivarus SAPE QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "BIVARUS28", "title": "Patient Reported Experience and Care Coordination", "description": "A composite score on this measure is derived from responses on 8 items (each item scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR composite measure.\n\nItems:\nBivarus 16: My Doctor Listened To Me\nBivarus 17: My Doctor Made Me Feel Comfortable Asking Questions\nBivarus 19: My Doctor Explained My Final Diagnosis\nBivarus 22: My Doctor Informed Me of My Treatment Options\nBivarus 23: My Doctor Told Me How Longs Things Would Take\nBivarus 24: My Doctor Did Not Seem Rushed With Me\nBivarus 25: While In My Room, My Doctor Was Focused On My Issues\nBivarus 26: How Likely Are You to Recommend This Physician To Your Family And Friends", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "patientEngagementExperience", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Bivarus SAPE QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "BIVARUS32", "title": "Patient Reported Care Team Communication", "description": "A composite score on this measure is derived from responses on 4 items (each item scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR composite measure. Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level. Items: Bivarus 7: Coordination of Care Among Physicians And Nurses Bivarus 9: I Was Told How to Arrange an Appointment for Follow-Up Care Bivarus 11: The Doctor Provided Follow-Up Care Instructions in A Way I Could Understand Bivarus 12: I Was Involved In Developing My Care or Follow-Up Plan", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Bivarus SAPE QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "BIVARUS33", "title": "Patient Reported Procedure Readiness and Care", "description": "A composite score on this measure is derived from responses on 10 items (each item scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR composite measure.\n\nBivarus (S-1): My surgeon's office adequately prepared me for my experience at [Insert Name] Surgery Center.\nBivarus (S-2): My doctor or care team explained the procedure before it was performed in a way I could understand.\nBivarus (S-3): Before my procedure, possible risks and side effects of the procedure were explained in a way I could understand\nBivarus (S-4): The anesthesia team explained the side effects of the medications I was to receive during my procedure.\nBivarus (S-5): Prior to starting, my care team confirmed the procedure to be performed with me in a way I could understand. Bivarus (D-1): Discharge and home care instructions were clearly explained in a way I could understand.\nBivarus (D-2): I was alerted to problems for which I should seek immediate medical attention should they occur after my procedure.\nBivarus (D-3): My care team explained how to manage any pain I felt after my procedure\nBivarus (D-4): My care team communicated with me about my care throughout my stay\nBivarus (D-5): My follow-up care was scheduled and explained in a way I could understand before discharge", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "patientEngagementExperience", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Bivarus SAPE QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP1", "title": "Turn-Around Time (TAT) - Standard biopsies", "description": "Measurement of the TAT for surgical pathology biopsy reports that meet a minimum 2 day requirement which is an indicator of a laboratory's efficiency and can also effect coordination of patient care.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP2", "title": "Cancer Protocol Elements for Carcinoma and Carcinosarcoma of the Endometrium", "description": "Cancer Protocol used for all eligible Carcinoma and Carcinosarcoma of the Endometrium specimens and all required data elements are included. The checklist covers the following procedure: Hysterectomy with/without salpingoophorectomy.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP3", "title": "Cancer Protocol Elements for Invasive Carcinoma of Renal Tubular Origin", "description": "Cancer protocol used for all eligible kidney resections and all required data elements are included. The checklist covers the following procedures:\na. Partial Nephrectomy\nb. Radical Nephrectomy", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP4", "title": "Cancer Protocol Elements for Carcinoma of the Intrahepatic Bile Ducts Completed", "description": "Cancer protocol used for all patients with carcinoma of the intrahepatic bile ducts and all required data elements are included. The checklist covers the following procedures: hepatic resection, partial or complete.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP5", "title": "Cancer Protocol Elements for Hepatocellular Carcinoma Completed", "description": "Cancer checklist used for all eligible hepatic resection specimens from patients with hepatocellular carcinoma and all required data elements are included. The checklist covers the following procedures: hepatic resection, partial or complete.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP6", "title": "Cancer Protocol Elements for Carcinoma of the Pancreas Completed", "description": "Cancer protocol used for all eligible all epithelial tumors of the pancreas, including high-grade neuroendocrine carcinomas. The protocol covers the following procedures:\n1. Partial Pancreatectomy\n2. Pancreaticoduodenectomy (Whipple Resection)\n3. Total Pancreatectomy", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP7", "title": "Helicobacter pylori documentation rate", "description": "Rate of Stomach Biopsy Cases with Gastritis and Documentation of the Presence or Absence of Helicobacter pylori", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP8", "title": "Turn-Around Time (TAT) - Lactate", "description": "The rate of cases in which the turn-around time target for lactate test ordered in the emergency room (ER) is met.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP9", "title": "Turn-Around Time (TAT) - Troponin", "description": "Rate of Cases in which the Turn-Around Time (TAT) target for Troponin Results Ordered in the Emergency Room (ER) is met", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CCOME1", "title": "1-Year Patient-Reported Pain and Function Improvement after Total Knee Arthroplasty", "description": "Percentage of patients 18 years of age and older who obtained at least a 10% improvement in knee pain or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and at least one year after undergoing primary total knee arthroplasty (TKA) surgery. PROMs include knee-related measures of pain and function (KOOS-Pain, KOOS-PS, KOOS-JR, KOOS-KRQoL).", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Cleveland Clinic OME", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CCOME2", "title": "1-Year Patient-Reported Pain and Function Improvement after Total Hip Arthroplasty", "description": "Percentage of patients 18 years of age and older who obtained at least a minimal clinically important difference (MCID) in hip pain or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and at least one year after undergoing primary total hip arthroplasty (THA) surgery. PROMs include hip-related measures of pain and function (HOOS-Pain, HOOS-PS, HOOS-JR).", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Cleveland Clinic OME", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CCOME3", "title": "1-Year Patient-Reported Pain and Function Improvement after Total Shoulder Arthroplasty", "description": "Percentage of patients 18 years of age and older who obtained at least a minimal clinically important difference (MCID) in shoulder pain or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and at least one year after undergoing primary total shoulder arthroplasty (TSA) surgery. PROMs include shoulder-related measures of pain and function (PSS-Pain, PSS-Function, PSS-Satisfaction).", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Cleveland Clinic OME", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CCOME4", "title": "1-Year Patient-Reported Pain and Function Improvement after ACLR Surgery", "description": "Percentage of patients 13 years of age and older who obtained at least a minimal clinically important difference (MCID) in knee pain or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and at least one year after undergoing primary anterior cruciate ligament reconstruction (ALCR) surgery. PROMs include knee-related measures of pain and function (KOOS-Pain, KOOS-PS, KOOS-JR, KOOS-KRQoL).", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Cleveland Clinic OME", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CCOME5", "title": "Extent of Osteoarthritis Observed in Arthroscopic Partial Meniscectomy", "description": "Percentage of patients aged 45 and higher undergoing primary arthroscopic partial meniscectomy (APM) surgery who do not have grade IV chondromalacia in more than one compartment. On a per-surgeon level, the measure is expected to be 70% or higher; on a system level, the measure is expected to be 80% or higher.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Cleveland Clinic OME", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CCOME6", "title": "1-Year Patient-Reported Pain and Function Improvement after APM Surgery", "description": "Percentage of patients 13 years of age and older who obtained at least a minimal clinically important difference (MCID) in knee pain or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and at least one year after undergoing primary arthroscopic partial meniscectomy (APM) surgery. PROMs include knee-related measures of pain and function (KOOS-Pain, KOOS-PS, KOOS-JR, KOOS-KRQoL).", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Cleveland Clinic OME", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CDR1", "title": "Adequate Off-loading of Diabetic Foot Ulcer at each visit", "description": "Percentage of visits in which diabetic foot ulcers among patients aged 18 years and received adequate off-loading during a 12-month reporting period, stratified by location of the ulcer.\n\nThe location of the diabetic foot ulcer on the foot (e.g. heel/midfoot vs. toes) determines the type of off-loading device that is appropriate, the patient's risk of falling, the probability of successful off-loading and thus the likelihood of major amputation. The clinician needs to assess the most appropriate off-loading option based on many different factors.\n\nThere are three rates reported for this measure.\nThe three rates will be risk stratified into two buckets (location of wound and/or ulcer) which are the following:\nRate 1:\tMidfoot/heel\nRate 2:\tToes\nRate 3:\tThe average of the two risk stratified buckets which will be the performance rate in the XML submitted.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "midfoot/heel", "description": "Midfoot/heel" }, { "name": "toes", "description": "Toes" }, { "name": "overall", "description": "The average of the two risk stratified buckets which will be the performance rate in the XML submitted." } ], "submissionMethods": [ "registry" ] }, { "measureId": "CDR2", "title": "Diabetic Foot Ulcer (DFU) Healing or Closure", "description": "Percentage of diabetic foot ulcers among patients age 18 or older that have achieved healing or closure within 6 months, stratified by the Wound Healing Index. Healing or closure is defined as complete epithelialization without drainage or the need for a dressing over the closed ulceration, although venous compression would still be required.\n\nThere are four rates reported for this measure.\nThree of the rates will be risk stratified into three buckets (minimum-maximum) which are the following:\nRate 1: 0.00 – 62.42\nRate 2: 62.42 – 73.19\nRate 3: 73.19 – 93.45\nRate 4: The average of the three risk stratified buckets which will be the performance rate in the XML submitted.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "bucket1", "description": "0.00 – 62.42" }, { "name": "bucket2", "description": "62.42 – 73.19" }, { "name": "bucket3", "description": "73.19 – 93.45" }, { "name": "overall", "description": "The average of the three risk stratified buckets which will be the performance rate in the XML submitted." } ], "submissionMethods": [ "registry" ] }, { "measureId": "CDR3", "title": "Plan of Care Creation for Diabetic Foot Ulcer (DFU) Patients not Achieving 30% Closure at 4 Weeks AND Plan of Care Creation for Venous Leg Ulcer (VLU) Patients not Achieving 30% Closure at 4 Weeks", "description": "Percentage of diabetic foot ulcers or venous leg ulcers of patients aged 18 years or from whom a plan of care was not created if they failed to achieve 30% of wound closure within 4 weeks. The plan of care will include a review of whether appropriate usual care has been implemented as well as whether an advanced therapeutic is indicated. Rate 1: Plan of Care Creation for Diabetic Foot Ulcer (DFU) Patients not Achieving 30% Closure at 4 Weeks ; Rate 2: Plan of Care Creation for Venous Leg Ulcer (VLU) Patients not Achieving 30% Closure at 4 Weeks", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "weightedAverage", "strata": [ { "name": "dfu", "description": "Plan of Care Creation for Diabetic Foot Ulcer (DFU) Patients not Achieving 30% Closure at 4 Weeks ;" }, { "name": "vlu", "description": "Plan of Care Creation for Venous Leg Ulcer (VLU) Patients not Achieving 30% Closure at 4 Weeks" } ], "submissionMethods": [ "registry" ] }, { "measureId": "CDR5", "title": "Adequate Compression at each visit for Patients with VLUs", "description": "Percentage of venous leg ulcer visits among patients aged 18 years and older in which adequate compression is provided within the 12-month reporting period. Compression method should be appropriate to documented arterial supply.\n\nThere are four rates reported for this measure.\nThe four rates will be risk stratified into three buckets which are the following:\nRate 1:\tNormal arterial supply- No restrictions on type of compression\nRate 2:\tCompression bandaging with special considerations (e.g. short stretch bandaging, warnings to the patient to remove bandages if they feel too tight, etc.)\nRate 3:\tCompression bandaging not usually recommended\nRate 4:\tThe average of the three risk stratified buckets which will be the performance rate in the XML submitted.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "normal", "description": "Normal arterial supply- No restrictions on type of compression" }, { "name": "considerations", "description": "Compression bandaging with special considerations (e.g. short stretch bandaging, warnings to the patient to remove bandages if they feel too tight, etc.)" }, { "name": "notrecommended", "description": "Compression bandaging not usually recommended" }, { "name": "overall", "description": "The average of the three risk stratified buckets which will be the performance rate in the XML submitted." } ], "submissionMethods": [ "registry" ] }, { "measureId": "CDR6", "title": "Venous Leg Ulcer (VLU) outcome measure: Healing or Closure", "description": "Percentage of venous leg ulcers among patients age 18 or older that have achieved healing or closure within 12 months, stratified by the Wound Healing Index. Healing or closure is defined as complete epithelialization without drainage or the need for a dressing over the closed ulceration, although venous compression would still be required. Three of the rates will be risk stratified into three buckets (minimum-maximum)which are the following:\nRate 1: 0.00-73.24\nRate 2: 73.24 - 80.26\nRate 3: 80.26 - 87.21\nRate 4: The average of the three risk stratified buckets which will be the performance rate in the XML submitted.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "bucket1", "description": "0.00-73.24" }, { "name": "bucket2", "description": "73.24 - 80.26" }, { "name": "bucket3", "description": "80.26 - 87.21" }, { "name": "overall", "description": "The average of the three risk stratified buckets which will be the performance rate in the XML submitted." } ], "submissionMethods": [ "registry" ] }, { "measureId": "CDR8", "title": "Appropriate Use of hyperbaric oxygen therapy for patients with diabetic foot ulcers", "description": "Percentage of visits in which diabetic foot ulcers among patients aged 18 years and older received adequate off-loading during a 12-month reporting period.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CDR9", "title": "Appropriate Use of Cellular and/or Tissue Based Product (CTP) in diabetic foot ulcers (DFUs) or venous leg ulcer (VLUs) among patients 18 years or older", "description": "Percent of patients 18 or older with venous or diabetic foot ulcer who receive cellular and/or tissue derived products appropriately as demonstrated by meeting all of the numerator targets of this problem and patient level composite measure: venous ulcer or diabetic foot ulcer did not achieve 30% closure within 4 weeks, patient underwent vascular screening, wound bed preparation with debridement of necrotic tissue, venous ulcer had adequate compression at each visit and diabetic foot ulcer had adequate off-loading at each visit.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CESQIP1", "title": "Post operative hypocalcemia after thyroidectomy surgery", "description": "The number or percent of patients with low calcium levels or negligible parathyroid hormone values reported at 30 days or more post op", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by Arbor-Metrix", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CESQIP2", "title": "Related readmission for thyroid or parathyroid related problems", "description": "Track all surgery related readmissions within 30 days after index surgery where reason for readmission is any of:\n 1. Hypocalcemia\n 2. Hematoma\n 3. Seroma\n 4. Wound infection\n 5. Rash\n 6. Dehydration\n 7. Lymphatic or thoracic duct leak\n 8. Suspected recurrent laryngeal nerve neuropraxia or voice hoarseness\n 9. Dysphagia\n 10. Pain\n 11. Tracheal injury or perforation\n 12. Esophageal injury or perforation\n 13. Lower extremity complication (Phlebitis)\n 14. Deep venous thrombosis\n 15. Pulmonary embolism (including respiratory distress)\n 16. Pulmonary (asthma, URI, pneumonia)\n 17. Gastrointestinal (diarrhea, constipation, SBO)\n 18. Nausea and/or vomiting\n 19. Genitourinary (UTI, urinary retention)\n 20. Myocardial Event (Atrial fib, CHF, MI, CVA)\n 21. Psychiatric/Neurological (anxiety, syncope, dizziness)", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by Arbor-Metrix", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CESQIP3", "title": "Pre operative ultrasound exam of patients with thyroid cancer", "description": "Documentation of use and efficacy of complete pre op cervical ultrasound exam in cancer patients", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by Arbor-Metrix", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CESQIP4", "title": "Persistent hypercalcemia", "description": "Patients with persistent elevated calcium after surgery", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by Arbor-Metrix", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CESQIP5", "title": "Related readmission for adrenal related problems", "description": "Track all surgery related readmissions within 30 days after index surgery where reason for readmission is any of:\n 1. Hematoma\n 2. Adrenal Insufficiency\n 3. Hypertension\n 4. Pain\n 5. Wound Infection\n 6. Pneumonia\n 7. Dehydration\n 8. Respiratory Distress", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by Arbor-Metrix", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CESQIP7", "title": "Vocal cord dysfunction following thyroidectomy", "description": "Vocal cord dysfunction following thyroidectomy", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by Arbor-Metrix", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CESQIP8", "title": "Hematoma requiring evacuation following thyroidectomy", "description": "Hematoma requiring evacuation following thyroidectomy", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by Arbor-Metrix", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CLLC1", "title": "Back Pain: Use of EMG & CNS", "description": "Percentage of patients with a diagnosis of axial lumbar, thoracic or cervical spine pain who had an electromyography (EMG) or nerve conduction study (NCS) within 30 days of the diagnosis", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Clinigence QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CLLC2", "title": "Morton's Neuroma - Avoidance of Alcohol Injections", "description": "Percentage of patients with a diagnosis of Morton's neuroma who received alcohol injections", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Clinigence QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CLLC3", "title": "Cancer Patients - Survivorship Care Plan", "description": "Percentage of patients with an encounter for follow-up examination after completed treatment for malignant neoplasm who have a survivorship care plan documented on the same date", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Clinigence QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CLLC4", "title": "Foot Bone Infection Diagnosis Without MRI", "description": "Percentage of patients with a diagnosis of bone infection (osteomyelitis) in the foot who had an MRI of the foot.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Clinigence QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CODE1", "title": "Improved Global Physical Health Outcome Assessment for Shoulder Replacement", "description": "Percentage of patients aged 18 years and older with primary shoulder replacement who completed baseline and follow-up (patient-reported) PROMIS Global 10 assessments that reported an improvement in global physical health.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "CODE Technology", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CODE10", "title": "Improved Global Physical Health Outcome Assessment for Shoulder Arthroscopy", "description": "Percentage of patients aged 18 years and older with primary shoulder arthroscopy who completed baseline and follow-up (patient-reported) PROMIS Global 10 assessments that reported an improvement in global physical health.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "CODE Technology", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CODE11", "title": "Improved Functional Outcome Assessment for Knee Arthroscopy", "description": "Percentage of patients aged 18 years and older with primary knee arthroscopy who completed baseline and follow-up (patient-reported) functional status assessments that reported a non-trivial improvement in functional status.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "CODE Technology", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CODE12", "title": "Improved Functional Outcome Assessment for Hip Arthroscopy", "description": "Percentage of patients aged 18 years and older with primary hip arthroscopy who completed baseline and follow-up (patient-reported) functional status assessments that reported a non-trivial improvement in functional status.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "CODE Technology", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CODE2", "title": "Improved Functional Outcome Assessment for ACL Repair", "description": "Percentage of patients aged 18 years and older with primary anterior cruciate ligament repair who completed baseline and follow-up (patient-reported) functional status assessments that reported a non-trivial improvement in functional status.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "CODE Technology", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CODE3", "title": "Improved Functional Outcome Assessment for Foot/Ankle Repair", "description": "Percentage of patients aged 18 years and older with primary foot/ankle repair who completed baseline and follow-up (patient-reported) functional status assessments that reported a non-trivial improvement in functional status.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "CODE Technology", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CODE5", "title": "Improved Global Physical Health Outcome Assessment for Spine Surgery", "description": "Percentage of patients aged 18 years and older with spine surgery who completed baseline and follow-up (patient-reported) PROMIS Global 10 assessments that reported an improvement in global physical health.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "CODE Technology", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CODE6", "title": "Improved Functional Outcome Assessment for Hip Replacement", "description": "Percentage of patients aged 18 years and older with primary hip replacement who completed baseline and follow-up (patient-reported) functional status assessments that reported a non-trivial improvement in functional status.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "CODE Technology", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CODE7", "title": "Improved Functional Outcome Assessment for Knee Replacement", "description": "Percentage of patients aged 18 years and older with primary knee replacement who completed baseline and follow-up (patient-reported) functional status assessments that reported a non-trivial improvement in functional status.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "CODE Technology", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CODE8", "title": "Improved Global Physical Health Outcome Assessment for Cervical Surgery", "description": "Patients with patient-reported PROMIS Global 10 assessment results not more than 180 days prior to the primary cervical surgery procedure, and at least 60 days and not more than 180 days after the procedure that demonstrated an improvement of at least 10% in global physical health.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "CODE Technology", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CODE9", "title": "Improved Global Physical Health Outcome Assessment for Hand/Wrist/Elbow Repair", "description": "Percentage of patients aged 18 years and older with primary hand/wrist/elbow repair who completed baseline and follow-up (patient-reported) PROMIS Global 10 assessments that reported an improvement in global physical health.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "CODE Technology", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CUHSM3", "title": "CAHPS Clinician/Group Surveys - (Adult Primary Care, Pediatric Care, and Specialist Care Surveys)", "description": "•Adult Primary Care Survey: 37 core and 64 supplemental question survey of adult outpatient primary care patients.\n Pediatric Care Survey: 36 core and 16 supplemental question survey of outpatient pediatric care patients.\n Specialist Care Survey: 37 core and 20 supplemental question survey of adult outpatients specialist care patients.\n Level of analysis for each of the 3 surveys: group practices, sites of care, and/or individual clinicians", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Consortium for Universal Health System Metrics", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CUHSM4", "title": "CAHPS Health Plan Survey v 4.0 - Adult questionnaire", "description": "30-question core survey of adult health plan members that assesses the quality of care and services they receive. Level of analysis: health plan – HMO, PPO, Medicare, Medicaid, commercial", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Consortium for Universal Health System Metrics", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CUHSM6", "title": "Adherence to Mood Stabilizers for Individuals with Bipolar I Disorder", "description": "Percentage of individuals at least 18 years of age as of the beginning of the measurement period with bipolar I disorder who had at least two prescription drug claims for mood stabilizer medications and had a Proportion of Days Covered (PDC) of at least 0.8 for mood stabilizer medications during the measurement period (12 consecutive months).", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Consortium for Universal Health System Metrics", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CUHSM8", "title": "Cardiovascular Health Screening for People With Schizophrenia or Bipolar Disorder Who Are Prescribed Antipsychotic Medications", "description": "The percentage of individuals 25 to 75 years of age with schizophrenia or bipolar disorder who were prescribed any antipsychotic medication and who received a cardiovascular health screening during the measurement year.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Consortium for Universal Health System Metrics", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CURE1", "title": "CureOneEGFR", "description": "Percentage of patients age 65 and older with newly diagnosed non-small cell lung cancer whose tumors have been tested for EGFR alterations and if positive treated with a corresponding FDA approved drug for EGFR per calendar year", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "CureOne", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CURE10", "title": "CureOneNSCLCBRAFTTP", "description": "Percentage of patients age 65 and older with newly diagnosed advanced non-small cell lung cancer found to have an BRAF alteration that are treated with FDA approved BRAF therapy whose disease does not progress within 6 months of starting the therapy", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "CureOne", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CURE11", "title": "CureOneMelBRAFTTP", "description": "Percentage of patients age 65 and older with newly diagnosed advanced melanoma found to have an BRAF alteration that are treated with FDA approved BRAF therapy whose disease does not progress within 6 months of starting the therapy", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "CureOne", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CURE2", "title": "CureOneALK", "description": "Percentage of patients age 65 and older with newly diagnosed advanced non-small cell lung cancer whose tumors have been tested for ALK rearrangements and if positive treated with a corresponding FDA approved drug for ALK per calendar year", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "CureOne", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CURE3", "title": "CureOneROS1", "description": "Percentage of patients age 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"nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ECPR46", "title": "Avoidance of Opiate Prescriptions for Low Back Pain or Migraines", "description": "Percentage of Patients with Low Back Pain and/or Migraines Who Were Not Prescribed an Opiate", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ECPR47", "title": "Avoidance of Opiate Prescriptions for Greater Than 3 Days Duration for Acute Pain", "description": "Percentage of Adult Patients Who Were Prescribed an Opiate for Whom the Prescription Duration Was Not Greater than 3 days for Acute Pain", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ECPR48", "title": "Avoidance of Long-Acting (LA) or Extended-Release (ER) Opiate Prescriptions", "description": "Percentage of Adult Patients Who Were Prescribed an Opiate Who Were Not Prescribed a Long-Acting (LA) or Extended-Release (ER) Formulation", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ECPR49", "title": "Avoidance of Tramadol or Codeine for Children", "description": "Percentage of Pediatric Patients Who Were Not Prescribed Tramadol or Codeine", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ECPR5", "title": "Mean Time from Emergency Department (ED) Arrival to ED Departure for Discharged Lower Acuity ED Patients", "description": "Mean Time from ED Arrival to Time of Departure from the ED for Lower Acuity Patients Discharged from the ED", "nationalQualityStrategyDomain": "Person and 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"firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ECPR6", "title": "Mean Time from Emergency Department (ED) Arrival to ED Departure for Discharged Higher Acuity ED Patients", "description": "Mean Time from ED Arrival to Time of Departure from the ED for Higher Acuity Patients Discharged from the ED", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "EPREOP28", "title": "Preoperative Frailty Assessment", "description": "Percentage of patients, aged 65 years and older, who undergo preoperative frailty assessment prior to elective surgery.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Registry (AQR QCDR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "EPREOP29", "title": "Preoperative Assessment for Opioid Dependence 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"nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Registry (AQR QCDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "FORCE20", "title": "Review of Functional Status Assessment for Patients with Osteoarthritis", "description": "Percentage of patients 18 years of age and older with osteoarthritis who completed baseline or follow-up patient-reported functional status assessment and reviewed the results of this assessment with their care provider.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences 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"primarySteward": "FORCE Ortho QI", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "FORCE22", "title": "Improvement in Pain after Knee Replacement", "description": "Percentage of patients aged 18 years or older with an elective primary total knee arthroplasty (TKA) in the first 9 months of the year with a change in their pain assessment score from before surgery to 3 months post surgery of at least 5 points measured by the KOOS pain assessment score.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "FORCE Ortho QI", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "FORCE23", "title": "Improvement in Pain after Hip Replacement", "description": "Percentage of patients aged 18 years or older with an elective primary total hip arthroplasty (THA) in the first 9 months of the year with a change in their pain assessment score from before surgery to 3 months post surgery of at least 12 points measured by the HOOS pain assessment score.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "FORCE Ortho QI", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "GIQIC10", "title": "Appropriate management of anticoagulation in the peri-procedural period rate – EGD", "description": "Percentage of patients undergoing an EGD on an anti-platelet agent or an anticoagulant who leave the endoscopy unit with instructions for management of this medication", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "GIQuIC", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "GIQIC12", "title": "Appropriate indication for colonoscopy", "description": "Percentage of colonoscopy procedures performed for an indication that is included in a published standard list of appropriate indications and the indication is documented", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "GIQuIC", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "GIQIC15", "title": "Appropriate follow-up interval of 3 years recommended based on pathology findings from screening 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"measureId": "GIQIC17", "title": "Appropriate follow-up interval of 5 years for colonoscopies with findings of sessile serrated polyps < 10 mm without dysplasia", "description": "Percentage of average-risk patients aged 50 years and older receiving a screening colonoscopy with biopsy or polypectomy and pathology findings of sessile serrated polyp(s) < 10 mm without dysplasia with a recommended follow-up interval of 5 years for repeat colonoscopy documented in their colonoscopy report", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "GIQuIC", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "GIQIC18", "title": "Appropriate follow-up interval of not less than 5 years for colonoscopies with findings of 1-2 tubular adenomas < 10 mm", "description": "Percentage of average-risk patients aged 50 years and older receiving a screening colonoscopy with biopsy or polypectomy and pathology findings of 1 of 2 tubular adenomas < 10 mm with a recommended follow-up interval of not less than 5 years for repeat colonoscopy documented in their colonoscopy report", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "GIQuIC", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "GIQIC19", "title": "Appropriate indication for esophagogastroduodenoscopy (EGD)", "description": "Percentage of esophagogastroduodenoscopy (EGD) procedures performed for an indication that is included in a published standard list of appropriate indications and the indication is documented", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "GIQuIC", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "GIQIC20", "title": "Appropriate follow-up interval of 10 years for colonoscopies with only hyperplastic polyp findings", "description": "Percentage of average-risk patients aged 50 years and older receiving a screening colonoscopy with biopsy or polypectomy and pathology findings of only hyperplastic polyp(s) with a recommended follow-up interval of 10 years for repeat colonoscopy documented in the colonoscopy report", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "GIQuIC", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HADV1", "title": "HAdv1 - Use of high risk sleep medications in the elderly", "description": "Percentage of patients aged 65 years and older for whom a high-risk sleep aid medication was prescribed for more than 30 days during the performance period.\n\nThis measure is reported once per reporting period for each patient having one or more denominator qualifying visits.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "HealthAdvanta", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HADV2", "title": "HAdv2 - Atrial Fibrillation Prevention and Treatment – Lifestyle and Disease Factor Assessment", "description": "Percentage of patients diagnosed with atrial fibrillation (afib) who are assessed for lifestyle and disease factors that contribute to uncontrolled atrial fibrillation at least once in the past 12 months.\n\nThis measure is reported once per reporting period for each patient having one or more denominator qualifying visits.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "HealthAdvanta", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HCPR13", "title": "Stroke Venous Thromboembolism (VTE) Prophylaxis", "description": "Percentage of Adult Ischemic and Hemorrhagic Stroke Patients Who Had VTE Prophylaxis Ordered on the Day Of or the Day After Hospital Admission OR Have Documentation of Why No VTE Prophylaxis Was Ordered", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "H-CPR (Hospitalist -Clinical Performance Registry)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HCPR14", "title": "Venous Thromboembolism (VTE) Prophylaxis", "description": "Percentage of Adult Patients Who Had VTE Prophylaxis Ordered on the Day Of or the Day After Hospital Admission OR Have Documentation of Why No VTE Prophylaxis Was Ordered", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "H-CPR (Hospitalist -Clinical Performance Registry)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HCPR16", "title": "Physician’s Orders for Life-Sustaining Treatment (POLST) Form", "description": "Percentage of Patients Aged 65 Years and Older with Physician’s Orders for Life-Sustaining Treatment (POLST) Forms Completed ", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "H-CPR (Hospitalist -Clinical Performance Registry)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HCPR17", "title": "Pressure Ulcers - Risk Assessment and Plan of Care", "description": "Percentage of Adult Post-acute Facility Patients That Had a Risk Assessment for Pressure Ulcers and a Plan of Care for Pressure Ulcer Prevention/Treatment Completed", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "H-CPR (Hospitalist -Clinical Performance Registry)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HCPR18", "title": "Unintentional Weight Loss - Risk Assessment and Plan of Care", "description": "Percentage of Adult Post-acute Facility Patients that Had a Risk Assessment for Unintentional Weight Loss and a Plan of Care for Unintentional Weight Loss Documented by Provider", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "H-CPR (Hospitalist -Clinical Performance Registry)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HCPR19", "title": "30 Day All-Cause Readmission Rate for Discharged Inpatients", "description": "Risk-Standardized Rate of All-cause Readmission to the Discharging Hospital and Hospitalist Physician Group within 30 Days of Initial Hospital Discharge Rate 1: Overall readmission rate, Rate 2: Readmission rate - pneumonia, Rate 3: Readmission rate - CHF, Rate 4: Readmission rate - COPD", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "H-CPR (Hospitalist -Clinical Performance Registry)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "HCPR20", "title": "Clostridium Difficile - Risk Assessment and Plan of Care", "description": "Percentage of Adult Patients Who Had a Risk Assessment for C. difficile Infection and, If High-Risk, Had a Plan of Care for C. difficile Completed on the Day Of or Day After Hospital Admission", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "H-CPR (Hospitalist -Clinical Performance Registry)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HCPR21", "title": "Appropriate Use of Telemetry for Admission or Observation Placement", "description": "Percentage of Adult Patients with an Appropriate Diagnosis for Telemetry Admission or Observation Placement", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "H-CPR (Hospitalist -Clinical Performance Registry)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HCPR22", "title": "Critical Care Transfer of Care - Use of Verbal Checklist or Protocol", "description": "Percentage of Adult Patients Transferred from the Critical Care Service to a Non-critical Care Service Who Had Documented Use of a Verbal Protocol for the Transfer of Care Between the Transferring Clinician and the Accepting Clinician", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "H-CPR (Hospitalist -Clinical Performance Registry)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HCPR3", "title": "Mean Length of Stay for Inpatients – Pneumonia", "description": "Risk-Adjusted Mean LOS for All Inpatients Diagnosed with Pneumonia", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "H-CPR (Hospitalist -Clinical Performance Registry)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "HCPR4", "title": "Mean Length of Stay for Inpatients – CHF", "description": "Risk-Adjusted Mean LOS for All Inpatients Diagnosed with Congestive Heart Failure (CHF)", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "H-CPR (Hospitalist -Clinical Performance Registry)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "HCPR5", "title": "Mean Length of Stay for Inpatients – COPD", "description": "Risk-Adjusted Mean LOS for All Inpatients Diagnosed with Chronic Obstructive Pulmonary Disease (COPD)", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "H-CPR (Hospitalist -Clinical Performance Registry)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "HEF1", "title": "Exclusive Breast Milk Feeding", "description": "PC-05 Exclusive breast milk feeding during the newborn's entire hospitalization", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Health eFilings QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HF2", "title": "Surgical Reconstruction for Anterior Cruciate Ligament (ACL) Injury", "description": "The change in a validated knee measure score will be used as a performance measure for surgeons performing ACL reconstruction. Two measures will be created and reported by each surgeon. Surgeons will report the average knee measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted knee measure change score ratio by dividing the average patient knee measure change score by the average predicted patient knee measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level. Eligible validated knee patient reported outcome measures include: International Knee Documental Committee (IKDC) Subjective Knee Form (Pedi-IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Single Assessment Numeric Evaluation (SANE) [1]. Defining the population: CPT-4 procedure codes will be used to identify patients who received ACL reconstruction without treatment of chondral injury. ACL reconstruction during the reporting period CPT-4 Codes: 29888. Surgeons who performed a minimum of 25 ACL reconstructions a year will be eligible to submit this measure. Time period for data collection and reporting: This measure will be calculated using all patients who underwent ACL reconstruction during the observation period. Patients receiving ACL reconstruction during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the knee measure score are available. Measures: Two surgeon-level performance measures will be reported. The unadjusted measure will be the average 6-month knee measure change score across all ACL reconstruction patients treated by the surgeon. The adjusted measure will be the ratio of the average knee measure change score divided by the average predicted knee measure change score for all patients treated by the surgeon. Unadjusted measure: Average Knee Measure Change Score. NUMERATOR: Sum of knee measure change scores from pre-surgery to 6-months post-surgery across all ACL reconstruction patients in the denominator. DENOMINATOR: The number of all patients who received ACL reconstruction during the observation window from the surgeon. Type of score: Validated knee measure change score average. Risk adjusted measure: Knee Measure Change Score Ratio. NUMERATOR: Average 6-month knee measure change score for all ACL reconstruction patients treated by surgeon. DENOMINATOR: Average predicted 6-month knee measure change score for all ACL reconstruction patients treated by surgeon. Risk adjustment methods and variables: The predicted 6 month knee measure change scores are estimated for each patient using the Center for Effectiveness Research in Orthopaedics’ (CERortho) risk adjustment regression model that includes the following patient variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, history or prior knee surgery, sport participation/activity level, osteoarthritis, concomitant chondral injury, the baseline knee measure, and baseline measures of pain, knee function, and quality of life.[2-4]. Variables included in the current CERortho risk model are based on information in available databases. CERortho plans to constantly update these specified variables based on input from evaluated surgeons and specialty organizations. Appendix A contains the list of baseline concepts from peer-reviewed literature that are thought to affect outcomes of treatment and will be candidates for future inclusion in the model. Type of score: Ratio score; Interpretation of score: Surgeons with ratio scores equal to 1 have quality scores equal to the average surgeon given the characteristics of their patients. Surgeons with ratio scores greater than 1 had knee change scores higher than average. Surgeons with ratios scores less than 1 had knee change scores lower than average given the characteristics of their patients. Definitions: Patient’s Knee Measure Score: A knee measure score is produced when the patient answers a validated knee assessment administered in the clinic or through an online portal. Patient’s Knee Measure Change Score: A patient’s change score is calculated by subtracting the patient’s knee measure score at baseline from the patient’s knee measure score at 6 months. Patient’s Knee Measure Predicted Adjusted Change Score: Knee measure change scores for patients are risk adjusted using a regression model that includes the following independent variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, history or prior knee surgery, sport participation/activity level, osteoarthritis, concomitant chondral injury, the baseline knee measure, and baseline measures of pain, knee function, and quality of life.[2-4] The patient’s predicted knee measure change score is the dependent variable. The regression model produces a risk-adjusted predicted knee measure change score for each patient. Risk-adjusted Knee Measure Change Score Ratio: The ratio between the actual change scores and the predicted change scores (after risk adjustment) is the ratio score. The risk-adjusted knee measure change score represents risk-adjusted change corrected for patient characteristics. A risk-adjusted ratio score of one or greater should be interpreted as change scores that were as good as or better than predicted given the risk-adjustment variables of the patient. Risk-adjusted ratio change scores less than one should be interpreted as knee measure change scores that were less than predicted given the risk-adjustment variables of the patient. The surgeon ratio scores can be used to make comparisons across surgeons. Steps: 1. Prior to ACL reconstruction surgery the patient completes a baseline validated knee measure assessment which generates the patient’s knee measure score at baseline; 2. Six months after surgery, the patient completes the same validated knee measure assessment again, which generates the patient’s knee measure score at 6 months; 3. The patient’s raw, unadjusted knee measure change score is generated by subtracting the baseline score from the 6-month score; Unadjusted measure: 4. Patients’ knee measure change scores are averaged by surgeon. Adjusted measure:  5. A risk-adjusted knee measure change score is predicted using the CERortho risk-adjustment regression model. 6. Patients’ unadjusted and adjusted knee measure change scores are averaged by surgeon. 7. A risk-adjusted Knee Measure Change Score Ratio is generated for each surgeon. 8.The ratio scores for all surgeons in the database are ranked. See attached for references...", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Hawkins Foundation in Collaboration with SunCoast RHIO and CERortho", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "HF3", "title": "Shoulder Instability - Labral Reconstruction: Change in Validated Shoulder Patient Reported Outcome Measure Following Labral Reconstruction for Shoulder", "description": "The change in a validated shoulder measure score will be used as a performance measure for surgeons performing labral reconstruction for shoulder instability. Two measures will be created and reported by each surgeon. Surgeons will report the average shoulder measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted shoulder measure change score ratio by dividing the average patient shoulder measure change score by the average predicted patient shoulder measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level.\n\nEligible validated shoulder patient reported outcome measures include: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Western Ontario Shoulder Instability Index, Single Assessment Numeric Evaluation (SANE) [1]\n\nDefining the population:\nCPT-4 codes will be used to identify patients who received labral repair or reconstruction for shoulder instability.\n\nLabral repair or reconstruction for shoulder instability during the reporting period CPT-4 Codes: 29806, 29807, 23450, 23455, 23460, 23462, 23465, 23466, 23462, 29806, 23455, 23466, 23662, excluding revisions (23450 and 23460).\n\nSurgeons who performed a minimum of 25 labral repair or reconstruction procedures a year will be eligible to submit this measure.\nTime-period for data collection and reporting:\nThis measure will be calculated using all patients who underwent surgery for shoulder instability during the observation period. Patients receiving surgery for shoulder instability during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the shoulder measure score are available.\n\nMeasures:\nTwo surgeon-level performance measures will be reported. The unadjusted measure will be the average 6-month shoulder measure change score across all shoulder instability patients treated by the surgeon. The adjusted measure will be the ratio of the average shoulder measure change score divided by the average predicted shoulder measure change score for all patients treated by the surgeon.\nUnadjusted measure: Average Shoulder Measure Change Score", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Hawkins Foundation in Collaboration with SunCoast RHIO and CERortho", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "HF4", "title": "Shoulder Arthroscopy: Measure of Change in a Validated Shoulder Patient Reported Outcome Following Shoulder Arthroscopy", "description": "The change in a validated shoulder measure score will be used as a performance measure for surgeons performing shoulder arthroscopy which includes rotator cuff debridement, biceps tenodesis and acromioplasty procedures. Two measures will be created and reported by each surgeon. Surgeons will report the average shoulder measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted shoulder measure change score ratio by dividing the average patient shoulder measure change score by the average predicted patient shoulder measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level. Eligible validated shoulder patient reported outcome measures include: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Oxford Shoulder Score (OSS), Single Assessment Numeric Evaluation (SANE) [1]. Defining the population: CPT-4 codes will be used to identify patients who received shoulder arthroscopy surgery. Shoulder arthroscopy during the reporting period CPT-4 Codes: 29822, 29823, 29826, 29828, 23430, 29999. Surgeons who performed a minimum of 25 shoulder arthroscopy procedures a year will be eligible to submit this measure. Time period for data collection and reporting: This measure will be calculated using all patients who underwent shoulder arthroscopy during the observation period. Patients receiving shoulder arthroscopy during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the shoulder measure score are available. Measures: Two surgeon-level performance measures will be reported. The unadjusted measure will be the average 6-month shoulder measure change score across all shoulder arthroscopy patients treated by the surgeon. The adjusted measure will be the ratio of the average shoulder measure change score divided by the average predicted shoulder measure change score for all patients treated by the surgeon. Unadjusted measure: Average Shoulder Measure Change Score. NUMERATOR: Sum of shoulder measure change scores from pre-surgery to 6-months post-surgery across all shoulder arthroscopy patients in the denominator. DENOMINATOR: The number of all patients who received shoulder arthroscopy during the observation window from the surgeon. Type of score: Validated shoulder measure change score average. Risk adjusted measure: Shoulder Measure Change Score Ratio. NUMERATOR: Average 6-month shoulder measure change score for all shoulder arthroscopy patients treated by surgeon. DENOMINATOR: Average predicted 6-month shoulder measure change score for all shoulder arthroscopy patients treated by surgeon. Risk adjustment methods and variables: The predicted 6-month shoulder measure change scores are estimated for each patient using the Center for Effectiveness Research in Orthopaedics’ (CERortho) risk adjustment regression model that includes the following patient variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, prior shoulder surgery, tear size, concomitant shoulder procedures, the baseline shoulder measure score, and baseline measures of pain, shoulder function, and quality of life. [2-6]. Variables included in the current CERortho risk model are based on information in available databases. CERortho plans to constantly update these specified variables based on input from evaluated surgeons and specialty organizations. Appendix A contains the list of baseline concepts from peer-reviewed literature that are thought to affect outcomes of treatment and will be candidates for future inclusion in the model. Type of score: Ratio score; Interpretation of score: Surgeons with ratio scores equal to 1 have quality scores equal to the average surgeon given the characteristics of their patients. Surgeons with ratio scores greater than 1 had shoulder change scores higher than average. Surgeons with ratios scores less than 1 had shoulder change scores lower than average given the characteristics of their patients. Definitions: Patient’s Shoulder Measure Score: A shoulder measure score is produced when the patient answers a validated shoulder assessment administered in the clinic or through an online portal. Patient’s Shoulder Measure Change Score: A patient’s change score is calculated by subtracting the patient’s shoulder measure score at baseline from the patient’s shoulder measure score at 6 months. Patient’s Shoulder Measure Predicted Adjusted Change Score: Shoulder measure change scores for patients are risk adjusted using a regression model that includes the following independent variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, prior shoulder surgery, tear size, concomitant shoulder procedures, the baseline shoulder measure score, and baseline measures of pain, shoulder function, and quality of life. [2-6] The patient’s predicted shoulder measure change score is the dependent variable. The regression model produces a risk-adjusted predicted shoulder measure change score for each patient. Risk-adjusted Shoulder Measure Change Score Ratio: The ratio between the actual change scores and the predicted change scores (after risk adjustment) is the ratio score. The risk-adjusted shoulder measure change score represents risk-adjusted change corrected for patient characteristics. A risk-adjusted ratio score of one or greater should be interpreted as change scores that were as good as or better than predicted given the risk-adjustment variables of the patient. Risk-adjusted ratio change scores less than one should be interpreted as shoulder measure change scores that were less than predicted given the risk-adjustment variables of the patient. The surgeon ratio scores can be used to make comparisons across surgeons. Steps: 1. Prior to shoulder arthroscopy surgery the patient completes a baseline validated shoulder measure assessment which generates the patient’s shoulder measure score at baseline. 2. Six months after surgery, the patient completes the same validated shoulder measure assessment again, which generates the patient’s shoulder measure score at 6 months. 3. The patient’s raw, unadjusted shoulder measure change score is generated by subtracting the baseline score from the 6-month score. Unadjusted measure: 4. Patients’ shoulder measure change scores are averaged by surgeon. Adjusted measure: 5.A risk-adjusted shoulder measure change score is predicted using the CERortho risk-adjustment regression model. 6. Patients’ unadjusted and adjusted shoulder measure change scores are averaged by surgeon. 7. A risk-adjusted Shoulder Measure Change Score Ratio is generated for each surgeon. 8.The ratio scores for all surgeons in the database are ranked. See Attachment for References.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Hawkins Foundation in Collaboration with SunCoast RHIO and CERortho", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "HF5", "title": "Shoulder Arthroplasty: Change in a Validated Shoulder Patient Reported Outcome Measure Following Shoulder Arthroplasty", "description": "The change in a validated shoulder measure score will be used as a performance measure for surgeons performing shoulder arthroplasty which includes hemiarthroplasty, total anatomical and reverse arthroplasty procedures. Two measures will be created and reported by each surgeon. Surgeons will report the average shoulder measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted shoulder measure change score ratio by dividing the average patient shoulder measure change score by the average predicted patient shoulder measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level. Eligible validated shoulder patient reported outcome measures include: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Oxford Shoulder Score (OSS), Single Assessment Numeric Evaluation (SANE) [1] Defining the population: CPT-4 codes will be used to identify patients who received shoulder arthroplasty surgery. Shoulder arthroplasty during the reporting period CPT-4 Codes: 23470, 23472 (excluding 23 473 and 23474). Surgeons who performed a minimum of 25 shoulder arthroplasty procedures a year will be eligible to submit this measure. Time period for data collection and reporting: This measure will be calculated using all patients who underwent shoulder arthroplasty during the observation period. Patients receiving shoulder arthroplasty during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the shoulder measure score are available. Measures: Two surgeon-level performance measures will be reported. The unadjusted measure will be the average 6-month shoulder measure change score across all shoulder arthroplasty patients treated by the surgeon. The adjusted measure will be the ratio of the average shoulder measure change score divided by the average predicted shoulder measure change score for all patients treated by the surgeon. Unadjusted measure: Average Shoulder Measure Change Score NUMERATOR: Sum of shoulder measure change scores from pre-surgery to 6-months post-surgery across all shoulder arthroplasty patients in the denominator. DENOMINATOR: The number of all patients who received shoulder arthroplasty during the observation window from the surgeon. Type of score: Validated shoulder measure change score average Risk adjusted measure: Shoulder Measure Change Score Ratio NUMERATOR: Average 6-month shoulder measure change score for all shoulder arthroplasty patients treated by surgeon. DENOMINATOR: Average predicted 6-month shoulder measure change score for all shoulder arthroplasty patients treated by surgeon. Risk adjustment methods and variables: The predicted 6-month shoulder measure change scores are estimated for each patient using the Center for Effectiveness Research in Orthopaedics’ (CERortho) risk adjustment regression model that includes the following patient variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, prior shoulder surgery, fracture, glenoid type, arthroplasty type (reverse vs. traditional total, hemi), the baseline shoulder measure, and baseline measures of pain, shoulder function, and quality of life.[2-6] Variables included in the current CERortho risk model are based on information in available databases. CERortho plans to constantly update these specified variables based on input from evaluated surgeons and specialty organizations. Appendix A contains the list of baseline concepts from peer-reviewed literature that are thought to affect outcomes of treatment and will be candidates for future inclusion in the model. Type of score: Ratio score Interpretation of score: Surgeons with ratio scores equal to 1 have quality scores equal to the average surgeon given the characteristics of their patients. Surgeons with ratio scores greater than 1 had shoulder change scores higher than average. Surgeons with ratios scores less than 1 had shoulder change scores lower than average given the characteristics of their patients. Definitions: Patient’s Shoulder Measure Score: A shoulder measure score is produced when the patient answers a validated shoulder assessment administered in the clinic or through an online portal. Patient’s Shoulder Measure Change Score: A patient’s change score is calculated by subtracting the patient’s shoulder measure score at baseline from the patient’s shoulder measure score at 6 months. Patient’s Shoulder Measure Predicted Adjusted Change Score: Shoulder measure change scores for patients are risk adjusted using a regression model that includes the following independent variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, prior shoulder surgery, fracture, glenoid type, arthroplasty type (reverse vs. traditional total, hemi), the baseline shoulder measure, and baseline measures of pain, shoulder function, and quality of life.[2-6] The patient’s predicted shoulder measure change score is the dependent variable. The regression model produces a risk-adjusted predicted shoulder measure change score for each patient. Risk-adjusted Shoulder Measure Change Score Ratio: The ratio between the actual change scores and the predicted change scores (after risk adjustment) is the ratio score. The risk-adjusted shoulder measure change score represents risk-adjusted change corrected for patient characteristics. A risk-adjusted ratio score of one or greater should be interpreted as change scores that were as good as or better than predicted given the risk-adjustment variables of the patient. Risk-adjusted ratio change scores less than one should be interpreted as shoulder measure change scores that were less than predicted given the risk-adjustment variables of the patient. The surgeon ratio scores can be used to make comparisons across surgeons. Steps: 1. Prior to shoulder arthroplasty surgery the patient completes a baseline validated shoulder measure assessment which generates the patient’s shoulder measure score at baseline. 2. Six months after surgery, the patient completes the same validated shoulder measure assessment again, which generates the patient’s shoulder measure score at 6 months. 3. The patient’s raw, unadjusted shoulder measure change score is generated by subtracting the baseline score from the 6-month score. Unadjusted measure: 4. Patients’ shoulder measure change scores are averaged by surgeon. Adjusted measure: 5. A risk-adjusted shoulder measure change score is predicted using the CERortho risk-adjustment regression model. 6. Patients’ unadjusted and adjusted shoulder measure change scores are averaged by surgeon. 7. A risk-adjusted Shoulder Measure Change Score Ratio is generated for each surgeon. 8. The ratio scores for all surgeons in the database are ranked. See attachment for references.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Hawkins Foundation in Collaboration with SunCoast RHIO and CERortho", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "HF6", "title": "Knee Arthroscopy for Meniscal Repair: Change in a Validated Knee Patient Reported Outcome Measure Following Knee Arthroscopy for Meniscal Repair", "description": "The change in a validated knee measure score will be used as a performance measure for surgeons performing knee arthroscopy for meniscal repair. Two measures will be created and reported by each surgeon. Surgeons will report the average knee measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted knee measure change score ratio by dividing the average patient knee measure change score by the average predicted patient knee measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level. Eligible validated knee patient reported outcome measures include: International Knee Documental Committee (IKDC) Subjective Knee Form (Pedi-IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Single Assessment Numeric Evaluation (SANE) [1]Defining the population:\nCPT-4 procedure codes will be used to identify patients who received knee arthroscopy for meniscal repair. Meniscal repair during the reporting period CPT-4 Codes: 29882, 29883. Excluding concurrent procedures including Anterior Cruciate Ligament Reconstruction (29888). Surgeons who performed a minimum of 25 meniscal repair procedures a year will be eligible to submit this measure. Time period for data collection and reporting:\nThis measure will be calculated using all patients who underwent meniscal repair during the observation period. Patients receiving meniscal repair during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the knee measure score are available. Measures: Two surgeon-level performance measures will be reported. The unadjusted measure will be the average 6-month knee measure change score across all meniscal repair patients treated by the surgeon. The adjusted measure will be the ratio of the average knee measure change score divided by the average predicted knee measure change score for all patients treated by the surgeon. Unadjusted measure: Average Knee Measure Change Score. NUMERATOR: Sum of knee measure change scores from pre-surgery to 6-months post-surgery across all meniscal repair patients in the denominator. DENOMINATOR: The number of all patients who received meniscal repair during the observation window from the surgeon. Type of score: Validated knee measure change score average; Risk adjusted measure: Knee Measure Change Score Ratio. NUMERATOR: Average 6-month knee measure change score for all meniscal repair patients treated by surgeon. DENOMINATOR: Average predicted 6-month knee measure change score for all meniscal repair patients treated by surgeon. Risk adjustment methods and variables: The predicted 6-month knee measure change scores are estimated for each patient using the Center for Effectiveness Research in Orthopaedics’ (CERortho) risk adjustment regression model that includes the following patient variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, history or prior knee surgery, sport participation/activity level, osteoarthritis, concomitant chondral injury, the baseline knee measure, and baseline measures of pain, knee function, and quality of life.[2-4] Variables included in the current CERortho risk model are based on information in available databases. CERortho plans to constantly update these specified variables based on input from evaluated surgeons and specialty organizations. Appendix A contains the list of baseline concepts from peer-reviewed literature that are thought to affect outcomes of treatment and will be candidates for future inclusion in the model.\nType of score: Ratio score\nInterpretation of score:\nSurgeons with ratio scores equal to 1 have quality scores equal to the average surgeon given the characteristics of their patients. Surgeons with ratio scores greater than 1 had knee change scores higher than average. Surgeons with ratios scores less than 1 had knee change scores lower than average given the characteristics of their patients. Definitions:\nPatient’s Knee Measure Score: A knee measure score is produced when the patient answers a validated knee assessment administered in the clinic or through an online portal.\nPatient’s Knee Measure Change Score: A patient’s change score is calculated by subtracting the patient’s knee measure score at baseline from the patient’s knee measure score at 6 months. Patient's Knee Measure Predicted Adjusted Change Score: Knee measure change scores for patients are risk adjusted using a regression model that includes the following independent variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, history or prior knee surgery, sport participation/activity level, osteoarthritis, concomitant chondral injury, the baseline knee measure, and baseline measures of pain, knee function, and quality of life.[2-4] The patient’s predicted knee measure change score is the dependent variable. The regression model produces a risk-adjusted predicted knee measure change score for each patient. Risk-adjusted Knee Measure Change Score Ratio: The ratio between the actual change scores and the predicted change scores (after risk adjustment) is the ratio score. The risk-adjusted knee measure change score represents risk-adjusted change corrected for patient characteristics. A risk-adjusted ratio score of one or greater should be interpreted as change scores that were as good as or better than predicted given the risk-adjustment variables of the patient. Risk-adjusted ratio change scores less than one should be interpreted as knee measure change scores that were less than predicted given the risk-adjustment variables of the patient. The surgeon ratio scores can be used to make comparisons across surgeons. Steps: 1. Prior to meniscal repair surgery the patient completes a baseline validated knee measure assessment which generates the patient’s knee measure score at baseline. 2. Six months after surgery, the patient completes the same validated knee measure assessment again, which generates the patient’s knee measure score at 6 months. 3. The patient’s raw, unadjusted knee measure change score is generated by subtracting the baseline score from the 6-month score. Unadjusted measure: 4. Patients’ knee measure change scores are averaged by surgeon. Adjusted measure: 5. A risk-adjusted knee measure change score is predicted using the CERortho risk-adjustment regression model. 6. Patients’ unadjusted and adjusted knee measure change scores are averaged by surgeon. 7. A risk-adjusted Knee Measure Change Score Ratio is generated for each surgeon. 8. The ratio scores for all surgeons in the database are ranked. See attachment for references.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Hawkins Foundation in Collaboration with SunCoast RHIO and CERortho", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "HF7", "title": "Surgical Repair for Rotator Cuff Tear: Change in a Validated Shoulder Patient Reported Outcome Measure Following Surgical Rotator Cuff Repair", "description": "The change in a validated shoulder measure score will be used as a performance measure for surgeons performing rotator cuff repair. Two measures will be created and reported by each surgeon. Surgeons will report the average shoulder measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted shoulder measure change score ratio by dividing the average patient shoulder measure change score by the average predicted patient shoulder measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level. Eligible validated shoulder patient reported outcome measures include: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Oxford Shoulder Score (OSS), Single Assessment Numeric Evaluation (SANE) [1] Defining the population: CPT-4 codes will be used to identify patients who received a rotator cuff repair surgery. Arthroscopic rotator cuff repair during the reporting period CPT-4 Codes: 29827, 29826 Surgeons who performed a minimum of 25 rotator cuff repair procedures a year will be eligible to submit this measure. Time period for data collection and reporting: This measure will be calculated using all patients who underwent rotator cuff repair during the observation period. Patients receiving rotator cuff repair during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the shoulder measure score are available. Measures: Two surgeon-level performance measures will be reported. The unadjusted measure will be the average 6 month shoulder measure change score across all rotator cuff repair patients treated by the surgeon. The adjusted measure will be the ratio of the average shoulder measure change score divided by the average predicted shoulder measure change score for all patients treated by the surgeon. Unadjusted measure: Average Shoulder Measure Change Score NUMERATOR: Sum of shoulder measure change scores from pre-surgery to 6 month post-surgery across all rotator cuff repair patients in the denominator. DENOMINATOR: The number of all patients who received rotator cuff repair during the observation window from the surgeon. Type of score: Validated shoulder measure change score average Risk adjusted measure: Shoulder Measure Change Score Ratio NUMERATOR: Average 6-month shoulder measure change score for all rotator cuff repair patients treated by surgeon. DENOMINATOR: Average predicted 6-month shoulder measure change score for all rotator cuff repair patients treated by surgeon. Risk adjustment methods and variables: The predicted 6-month shoulder measure change scores are estimated for each patient using the Center for Effectiveness Research In Orthopaedics’ (CERortho) risk adjustment regression model that includes the following patient variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, prior shoulder surgery, tear size, tendon quality, the baseline shoulder measure score, and baseline measures of pain, shoulder function, and quality of life. [2, 3] Variables included in the current CERortho risk model are based on information in available databases. CERortho plans to constantly update these specified variables based on input from evaluated surgeons and specialty organizations. Appendix A contains the list of baseline concepts from the literature and American Academy of Orthopaedic Surgeons (AAOS) and peer-reviewed literature that are thought to affect outcomes of treatment and will be candidates for future inclusion in the model. [2, 3] Type of score: Ratio score; Interpretation of score: Surgeons with ratio scores equal to 1 have quality scores equal to the average surgeon given the characteristics of their patients. Surgeons with ratio scores greater than 1 had shoulder change scores higher than average. Surgeons with ratios scores less than 1 had shoulder change scores lower than average given the characteristics of their patients. Definitions: Patient’s Shoulder Measure Score: A shoulder measure score is produced when the patient answers a validated shoulder assessment administered in the clinic or through an online portal. Patient’s Shoulder Measure Change Score: A patient’s change score is calculated by subtracting the patient’s shoulder measure score at baseline from the patient’s shoulder measure score at 6 month. Patient’s Shoulder Measure Predicted Adjusted Change Score: Shoulder measure change scores for patients are risk adjusted using a regression model that includes the following independent variables age, gender, BMI, smoking status, comorbidities, worker’s compensation status, prior shoulder surgery, tear size, tendon quality, the baseline shoulder measure score, and baseline measures of pain, shoulder function, and quality of life. [2, 3] The patient’s predicted shoulder measure change score is the dependent variable. The regression model produces a risk-adjusted predicted shoulder measure change score for each patient. Risk-adjusted Shoulder Measure Change Score Ratio: The ratio between the actual change scores and the predicted change scores (after risk adjustment) is the ratio score. The risk-adjusted shoulder measure change score represents risk-adjusted change corrected for patient characteristics. A risk-adjusted ratio score of one or greater should be interpreted as change scores that were as good as or better than predicted given the risk-adjustment variables of the patient. Risk-adjusted ratio change scores less than one should be interpreted as shoulder measure change scores that were less than predicted given the risk-adjustment variables of the patient. The surgeon ratio scores can be used to make comparisons across surgeons. Steps: 1. Prior to rotator cuff repair surgery the patient completes a baseline validated shoulder measure assessment which generates the patient’s shoulder measure score at baseline. 2. Six months after surgery, the patient completes the same validated shoulder measure assessment again, which generates the patient’s shoulder measure score at 6 months. 3. The patient’s raw, unadjusted shoulder measure change score is generated by subtracting the baseline score from the 6-month score. Unadjusted measure: 4. Patients’ shoulder measure change scores are averaged by surgeon. Adjusted measure: 5. A risk-adjusted shoulder measure change score is predicted using the CERortho risk-adjustment regression model. 6. Patients’ unadjusted and adjusted shoulder measure change scores are averaged by surgeon. 7. A risk-adjusted Shoulder Measure Change Score Ratio is generated for each surgeon. 8. The ratio scores for all surgeons in the database are ranked.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Hawkins Foundation in Collaboration with SunCoast RHIO and CERortho", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "HM1", "title": "ACE/ARB use", "description": "Percentage of T2D patients age 18-75 with elevated urinary protein excretions and/or reduced eGFR for whom an ACE or ARB has been prescribed", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Diabetes QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HM2", "title": "A1C treatment", "description": "Percentage of T2D patients 18-75 years of age with A1C ≥8.0% not at A1C goal who are treated with metformin", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Diabetes QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HM3", "title": "A1C in good control", "description": "Percentage of T2D patients 18-75 years of age by the end of the measurement period who had most recent hemoglobin less than 8.0%", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Diabetes QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IQSS1", "title": "Hypogonadism: Serum T, CBC, PSA, IPSS within 6 months of Rx", "description": "Percentage of patients with a new diagnosis of hypogonadism (257.2) receiving androgen replacement therapy who have serum T, CBC, PSA, and IPSS documented within 6 months of first treatment", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "IntrinsiQ Specialty Solutions (IQSS)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IQSS2", "title": "Prostate Cancer: Newly diagnosed with document T, PSA, Gleason and Prostate Cancer: Initial Eval. Document T, PSA, Gleason", "description": "Percentage of newly diagnosed prostate cancer patients who prior to treatment have a documented evaluation of primary tumor (T) stage, PSA score, and Gleason score", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "IntrinsiQ Specialty Solutions (IQSS)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IQSS3", "title": "Prostate Cancer: Treatment Options Counseling", "description": "Newly diagnosed prostate cancer patients receiving definitive local treatment (surgery, radiation, cryotherapy) with documented counseling of all treatment options (active surveillance, surgery, radiation)", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "patientEngagementExperience", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "IntrinsiQ Specialty Solutions (IQSS)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IQSS4", "title": "BPH: Anticholinergics", "description": "Percentage of patients with BPH and treatment with anticholinergics where a PVR is performed", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "IntrinsiQ Specialty Solutions (IQSS)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IQSS5", "title": "Counseling SUI", "description": "Percentage of patients undergoing surgery for SUI where treatment counseling was documented prior to surgery", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "patientEngagementExperience", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "IntrinsiQ Specialty Solutions (IQSS)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS1", "title": "Endothelial Keratoplasty: Post-operative improvement in best corrected visual acuity to 20/40 or greater", "description": "Percentage of endothelial keratoplasty patients with a best corrected visual acuity of 20/40 or greater at 90 days after surgery.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS10", "title": "Exudative Age-Related Macular Degeneration - Loss of Visual Acuity", "description": "Percentage of patients with a diagnosis of exudative age-related macular degeneration, being treated with anti-VEGF agents, with of loss of less than 0.3 logMar of visual acuity within the past 12 months", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS11", "title": "Nonexudative Age-Related Macular Degeneration - Loss of Visual Acuity", "description": "Percentage of patients with a diagnosis of nonexudative age-related macular degeneration and taking AREDS supplements with of loss of less than 0.3 logMar of visual acuity within the past 12 months", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS13", "title": "Diabetic Macular Edema - Loss of Visual Acuity", "description": "Percentage of patients with a diagnosis of diabetic macular edema with of loss of less than 0.3 logMar of visual acuity within the past 12 months", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS16", "title": "Acute Anterior Uveitis - Post-treatment visual acuity", "description": "Percentage of acute anterior uveitis patients with a post-treatment best corrected visual acuity of 20/40 or greater OR patients whose visual acuity had returned to their baseline value prior to onset of uveitis", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS17", "title": "Acute Anterior Uveitis - Post-treatment Grade 0 anterior chamber cells", "description": "Percentage of patients with acute anterior uveitis post-treatment with Grade 0 anterior chamber cells", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS18", "title": "Chronic Anterior Uveitis - Post-treatment visual acuity", "description": "Percentage of chronic anterior uveitis patients with a post-treatment best corrected visual acuity of 20/40 or greater OR patients whose visual acuity had returned to their baseline value prior to onset of uveitis", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS2", "title": "Glaucoma - Intraocular Pressure (IOP) Reduction", "description": "Percentage of glaucoma patient visits where their IOP was below a threshold level based on the severity of their diagnosis", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS20", "title": "Idiopathic Intracranial Hypertension: No worsening or improvement of mean deviation", "description": "Percentage of patients with no worsening of perimetric mean deviation by > 3dB at 6 months or improvement in mean deviation at 6 months", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS21", "title": "Ocular Myasthenia Gravis: Improvement of ocular deviation or absence of diplopia or functional improvement", "description": "Percentage of patients with improvement of ocular deviation or absence of diplopia in primary gaze after treatment or functional improvement of ptosis at 6 months", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS22", "title": "Giant Cell Arteritis: Absence of fellow eye involvement after treatment", "description": "Percentage of patients without fellow eye involvement 1-26 weeks after initiating treatment in patients with unilateral visual loss", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS23", "title": "Refractive Surgery: Postoperative Improvement in Uncorrected Visual Acuity of 20/20 or better", "description": "Percentage of patients receiving refractive surgery for myopia with a postoperative uncorrected visual acuity (UCVA) of 20/20 or better", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS24", "title": "Refractive Surgery: Postoperative correction within + 0.5 Diopter of the Intended Correction", "description": "Percentage of patients with a postoperative spherical equivalent (SE) within + 0.5 Diopter (D) of the intended correction or SE", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS25", "title": "Adenoviral Conjunctivitis: Avoidance of Antibiotics", "description": "Percentage of patients who received antibiotic treatment for adenoviral conjunctivitis", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS26", "title": "Intravitreal Injections: Avoidance of Routine Antibiotic Use", "description": "The percentage of patients who received antibiotics before or after intravitreal injections", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS27", "title": "Adverse Events After Cataract Surgery", "description": "Percentage of patients aged 18 years and older with a diagnosis of cataract who had cataract surgery and had the following complications with 90 days after cataract surgery: prolonged inflammation, incision complications, iris complications, retinal detachment, cystoid macular edema, corneal complications.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS28", "title": "Regaining Vision After Cataract Surgery", "description": "Percentage of patients aged 18 years and older with a diagnosis of cataract who had cataract surgery and had a best-corrected distance visual acuity of 20/20 or better achieved within 30 days following the cataract surgery.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS29", "title": "Improved visual acuity after epiretinal membrane treatment within 90 days", "description": "Percentage of patients with improved vision following epiretinal membrane treatment", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS3", "title": "Glaucoma - Visual Field Progression", "description": "Percentage of eyes, in patients with a diagnosis of glaucoma, with a mean deviation loss of more than 3dB from their baseline value.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS30", "title": "Return to OR within 90 days after epiretinal membrane surgical treatment", "description": "Return to OR within 90 days after epiretinal membrane surgical treatment", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS31", "title": "Avoidance of Genetic Testing for Age-related Macular Degeneration", "description": "Percentage of patients with Age-Related Macular Degeneration (AMD) who have received a genetic test for the purpose of AMD treatment (and not research).", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS32", "title": "Evidence of anatomic closure of macular hole within 90 days after surgery as documented by OCT.", "description": "Percentage of patients with a macular hole who have evidence of anatomic closure within 90 days after surgical treatment.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS33", "title": "Return to OR within 90 days after macular hole surgery", "description": "Percentage of patients with a macular hole who returned to the OR with complications within 90 days after surgical treatment for macular hole.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS34", "title": "Age-Related Macular Degeneration: Disease Progression", "description": "Percentage of patients with nonexudative age-related macular degeneration progressing to exudative age-related macular degeneration within the past 12 months.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS4", "title": "Glaucoma - Intraocular Pressure Reduction Following Laser Trabeculoplasty", "description": "Percentage of patients who underwent laser trabeculoplasty who had IOP reduced by 20% from their pretreatment level", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS5", "title": "Surgery for Acquired Involutional Ptosis - Patients with an Improvement of Marginal Reflex Distance", "description": "Percentage of surgical ptosis patients with an improvement of MRD postoperatively within 90 days following the surgical procedure", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS6", "title": "Acquired Involutional Entropion - Normalized Lid Position After Surgical Repair", "description": "Percentage of surgical entropion patients with postoperative normalized lid position", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS7", "title": "Amblyopia - Interocular Visual Acuity", "description": "Percentage of newly diagnosed amblyopic patients with an improvement in visual acuity after treatment within 6 -12 months of first diagnosis", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS8", "title": "Surgical Esotropia - Postoperative Alignment", "description": "Percentage of surgical esotropia patients with a postoperative alignment of 15 prism diopters (PD) or less", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS9", "title": "Diabetic Retinopathy - Documentation of the Presence or Absence of Macular Edema and the Level of Severity of Retinopathy", "description": "Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IROMS1", "title": "Functional Improvement in hip, leg or ankle rehabilitation in patients with lower extremity injury measured via the validated Lower Extremity Function Scale (LEFS) score.", "description": "The average LEFS change score for patients with hip, leg, or ankle injuries treated during the observation period will be reported.\n\nAdditionally, a risk-adjusted LEFS change difference score will be calculated by subtracting the predicted LEFS change score from the average LEFS change score for each patient, then average the adjusted scores for each physical therapist or physical therapy group. The risk adjustment will be calculated using generalized linear modelling adjusting for: baseline LEFS score, baseline pain score, age, sex, smoking, comorbidities, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).\n\nThese measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level. Rate 1: Average LEFS Change Score, Rate 2: Risk-adjusted Average LEFS Change Score.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Intermountain ROMS", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "IROMS10", "title": "Functional Improvement in low back rehabilitation of non-surgical patients with low pack pain measured via the validated Modified Low Back Pain Disability Questionnaire (MDQ).", "description": "The average MDQ change score for patients with low back pain treated during the observation period will be reported.\n\nAdditionally, a risk-adjusted MDQ change difference score will be calculated by subtracting the predicted MDQ change score from the average MDQ change score for each patient, then average the adjusted scores for each physical therapist or physical therapy group. The risk adjustment will be calculated using generalized linear modelling adjusting for: baseline MDQ score, baseline pain score, age, sex, smoking, comorbidities, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).\n\nThese measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level. Rate 1: Average MDQ Change Score, Rate 2: Risk-adjusted Average MDQ Change Score for each of the following: 1) Overall (all eligible patients), 2) non-surgical patients, 3 surgical patients.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Intermountain ROMS", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "IROMS2", "title": "Functional Improvement in knee rehabilitation of patients with knee injury measured via their validated Knee Outcome Survey (KOS) score.", "description": "The average KOS change score for patients with knee injury patients treated during the observation period will be reported.\n\nAdditionally, a risk-adjusted KOS change difference score will be calculated by subtracting the predicted KOS change score from the average KOS change score for each patient, then average the adjusted scores for each physical or occupational therapist (PT or OT) or PT or OT group. The risk adjustment will be calculated using generalized linear modelling adjusting for: baseline KOS score, baseline pain score, age, sex, smoking, comorbidities, payer, and symptom duration (time from surgery or injury to baseline PT/OT visit).\n\nThese measures will serve as a PT/OT performance measure at the eligible PT/OT or PT/OT group level. Rate 1: Average KOS Change Score, Rate 2: Risk-adjusted Average KOS Change Score.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Intermountain ROMS", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "IROMS8", "title": "Functional Improvement in arm, shoulder, and hand rehabilitation in surgical patients with musculotendinous injury measured via the validated Disability of Arm Shoulder and Hand (DASH) score.", "description": "The average DASH change score for surgical patients with musculotendinous injury patients treated during the observation period will be reported.\n\nAdditionally, a risk-adjusted DASH change difference score will be calculated by subtracting the predicted DASH change score from the average DASH change score for each patient, then average the adjusted scores for each physical therapist or physical therapy group. The risk adjustment will be calculated using generalized linear modelling adjusting for: baseline DASH score, baseline pain score, age, sex, smoking, comorbidities, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).\n\nThese measures will serve as a physical and occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level. Rate 1: Average DASH Change Score, Rate 2: Risk-adjusted Average DASH Change Score.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Intermountain ROMS", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "IROMS9", "title": "Functional Improvement in neck pain/injury patients rehabilitation measured via the validated Neck Disability Index (NDI).", "description": "The average NDI change score for neck pain/injury patients treated during the observation period will be reported.\n\nAdditionally, a risk-adjusted NDI change difference score will be calculated by subtracting the predicted NDI change score from the average NDI change score for each patient, then average the adjusted scores for each physical therapist or physical therapy group. The risk adjustment will be calculated using generalized linear modelling adjusting for: baseline NDI score, baseline pain score, age, sex, smoking, comorbidities, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).\n\nThese measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level. Rate 1: Average NDI Change Score, Rate 2: Risk-adjusted Average NDI Change Score.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Intermountain ROMS", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "M2S1", "title": "M2S 1: Procedures with statin and antiplatelet agents prescribed at discharge", "description": "This measure estimates the frequency of procedures where a statin and antiplatelet agent was prescribed at discharge for any of the following procedures: Infra-Inguinal Bypass, Supra-Inguinal Bypass, Peripheral Vascular Intervention, Carotid Artery Stent, Carotid Endarterectomy, Thoracic and Complex EVAR, Endovascular AAA Repair, and Open AAA Repair.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Vascular Quality Initiative QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "M2S10", "title": "M2S 10: Survival at least 9 months after elective repair of small thoracic aortic aneurysms", "description": "This measure estimates freedom from death at least 9 months after elective repair of small thoracic aortic aneurysms in patients without a known connective tissue disorder.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Vascular Quality Initiative QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "M2S11", "title": "M2S 11: Imaging-based maximum aortic diameter assessed at least 9 months following Endovascular AAA Repair procedures", "description": "This measure estimates the frequency of imaging-based maximum aortic diameter assessment at least 9 months after Endovascular AAA Repair procedures.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Vascular Quality Initiative QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "M2S12", "title": "M2S 12: Survival at least 9 months after elective repair Endovascular AAA Repair of small abdominal aortic aneurysms", "description": "This measure estimates freedom from death at least 9 months after elective repair of small abdominal aortic aneurysms.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Vascular Quality Initiative QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "M2S13", "title": "M2S 13: Survival at least 9 months after elective Open AAA repair of small abdominal aortic aneurysms", "description": "This measure estimates freedom from death at least 9 months after elective open repair of small abdominal aortic aneurysms.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Vascular Quality Initiative QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "M2S16", "title": "Absence of unplanned reoperation after closed lower extremity major amputation", "description": "The percentage of patients undergoing closed lower extremity major amputation (below, thru or above knee) for ischemic arterial disease who do NOT have unplanned reoperation during the same admission for infection, bleeding or amputation revision.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Vascular Quality Initiative QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "M2S17", "title": "M2S 17: Absence of serious technical complications during peripheral arterial intervention", "description": "The percentage of patients undergoing lower extremity interventional treatment for arterial occlusive disease (including balloon angioplasty, stenting and atherectomy) who do NOT experience technical complications (Access site: stenosis, occlusion, AV fistula, hematoma or pseudoaneurysm, Thrombosis, Embolization, Perforation, or Dissection (target lesion or other artery) that require admission, or surgical or interventional treatment.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Vascular Quality Initiative QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "M2S19", "title": "M2S 19: Proper patient selection for perforator vein ablation", "description": "The percentage of patients undergoing treatment of incompetent lower extremity perforator veins with surgical or ablation treatment (radiofrequency, laser, mechanochemical, chemical, or embolic adhesive) who have CEAP clinical severity of disease C5 or C6 (venous ulcer or history of ulcer), and not less severe C1-4 disease.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Vascular Quality Initiative QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "M2S2", "title": "M2S 2: Amputation-free survival assessed at least 9 months following Infra-Inguinal Bypass for intermittent claudication", "description": "This measure estimates freedom from amputation or death at least 9 months after Infra-Inguinal Bypass for intermittent claudication.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Vascular Quality Initiative QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "M2S5", "title": "M2S 5: Amputation-free survival at assessed at least 9 months following Peripheral Vascular Intervention for intermittent claudication", "description": "This measure estimates freedom from amputation or death at least 9 months after Peripheral Vascular Intervention for intermittent claudication.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Vascular Quality Initiative QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "M2S7", "title": "M2S 7: Ipsilateral stroke-free survival at assessed at least 9 months following Carotid Artery Stenting for asymptomatic procedures", "description": "This measure estimates freedom from stroke or death at least 9 months after carotid artery stenting for asymptomatic carotid stenosis.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Vascular Quality Initiative QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "M2S8", "title": "M2S 8: Ipsilateral stroke-free survival assessed at least 9 months following isolated Carotid Endarterectomy for asymptomatic procedures", "description": "This measure estimates freedom from stroke or death at least 9 months after carotid endarterectomy for asymptomatic carotid artery stenosis.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Vascular Quality Initiative QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "M2S9", "title": "M2S 9: Imaging-based maximum aortic diameter assessed at least 9 months following Thoracic and Complex EVAR procedures", "description": "This measure estimates the frequency of imaging-based maximum aortic diameter assessment at least 9 months after Thoracic and Complex EVAR procedures.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Vascular Quality Initiative QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MA1", "title": "Case Delay", "description": "Percentage of anesthesia cases or procedures which are delayed greater than 15 minutes after the scheduled start with a reason indicated. Rate 1: Advance 3B - Procedure delayed from scheduled start time; Rate 2: Advance 3C - Reason for delay indicated", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "efficiency", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Advance QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "delayed", "description": "Advance 3B - Procedure delayed from scheduled start time;" }, { "name": "overall", "description": "Advance 3C - Reason for delay indicated" } ], "submissionMethods": [ "registry" ] }, { "measureId": "MA3", "title": "Corneal Abrasion", "description": "Percentage of patients, aged 18 years or older, who undergo anesthesia care and did not have a new diagnosis of corneal injury within 24 hours of anesthesia", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Advance QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MBHR1", "title": "Anxiety Utilization of the GAD-7 Tool", "description": "The percentage of adult patients (18 years and older) with an anxiety disorder diagnosis (generalized anxiety disorder, social anxiety disorder, post-traumatic stress disorder, or panic disorder) who have completed GAD-7 tool during measurement period", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MBHR- Mental and Behavioral Health Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MBHR2", "title": "Anxiety Response at 6-months", "description": "The percentage of adult patients (18 years of age or older) with an anxiety disorder (generalized anxiety disorder, social anxiety disorder, post-traumatic stress disorder, or panic disorder) who demonstrated a response to treatment at six months (+/- 60 days) after an index visit", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "MBHR- Mental and Behavioral Health Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MBSAQIP10", "title": "Risk standardized rate of patients who experienced a postoperative escalation in care event following a primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation", "description": "Primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy patients who experienced a postoperative escalation in care event", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MBSAQIP11", "title": "Risk standardized rate of patients who experienced a pulmonary complication following a primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy", "description": "Primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy patients who experienced a pulmonary complication", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MBSAQIP12", "title": "Risk standardized rate of patients who experienced a postoperative complication following a primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation", "description": "Primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy patients who experienced a postoperative complication", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": false, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MBSAQIP7", "title": "Risk standardized rate of patients who experienced postoperative nausea, vomiting or fluid/electrolyte/nutritional depletion following a primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation", "description": "Primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy patients who experienced postoperative nausea, vomiting or fluid/electrolyte/nutritional depletion", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MBSAQIP8", "title": "Risk standardized rate of patients who experienced an extended length of stay (> 3 days) following a primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation", "description": "Primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy patients who experienced an extended length of stay (> 3 days)", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MEDNAX52", "title": "Use of a “PEG Test” to Manage Patients Receiving Opioids", "description": "Percentage of patients in an outpatient setting, aged 18 and older, in whom a stable dose of opioids are prescribed for greater than 6 weeks for pain control, and the results of a “PEG Test” are correctly interpreted and applied to the management of their opioid prescriptions.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MEDNAX QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MEX1", "title": "MEX1: Heel Pain Treatment Outcomes for Adults", "description": "DESCRIPTION:\nPercentage of patients aged 18 years and older with a diagnosis of heel pain who had two or more encounters in the past year.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Med-Xpress Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MEX10", "title": "Vascular Testing Outcome Measure Supervised Programs", "description": "Percentage of patients aged 18 years and older with a previously abnormal non invasive vascular study who successfully completed a 12 week supervised program", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Med-Xpress Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MEX11", "title": "MEX2018-19: Non-Invasive Vascular Testing in Patients with Abnormal CVI Screening That Completed Hyperbaric Oxygen Therapy", "description": "Percentage of patients aged 18 years and older with an abnormal CVI screening who completed hyperbaric oxygen therapy", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Med-Xpress Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MEX12", "title": "Peripheral Vascular Assessment % of Diabetic Patients 50+", "description": "Percentage of diabetic patients aged 50 and older who undergo a peripheral vascular assessment", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Med-Xpress Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MEX13", "title": "MEX2018-22: Patients with Lower Limb Ulceration with a Previously Abnormal Vascular Study Receiving Negative Pressure Wound Therapy", "description": "Percentage of patients aged 18 years and older with a previous abnormal vascular study and a lower limb ulceration that underwent negative pressure wound therapy", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Med-Xpress Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MEX2", "title": "MEX2: Heel Pain Treatment Outcomes for Pediatric Patients", "description": "Percentage of patients aged 6 to 18 years with a diagnosis of heel pain who experience a decrease in heel pain.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Med-Xpress Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MEX3", "title": "MEX3: Identification of Flat Foot in Pediatric Patients", "description": "Percentage of patients aged 6 - 18 years with a diagnosis of flat foot who had an encounter and treatment for flexible flat foot in the past year.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Med-Xpress Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MEX4", "title": "MEX2018-2: Bunion Outcome - Adult and Adolescent", "description": "Percentage of patients with a who have a hallux valgus (bunion) deformity causing pain", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Med-Xpress Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MEX5", "title": "MEX2018-3: Hammer Toe Outcome", "description": "Percentage of patients who have a painful hammer toe, claw toe, mallet toe or other lesser toe deformity causing disability", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Med-Xpress Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MEX6", "title": "MEX2018-11: Peripheral Vascular Assessment - Patients 70+", "description": "Percentage of patients aged 70 and older who undergo a peripheral vascular assessment", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Med-Xpress Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MEX7", "title": "MEX2018-6: Foot Wound Outcome", "description": "Percentage of patients aged 18 years and older who have a pressure ulcer or non-pressure ulcer of the foot or ankle", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Med-Xpress Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MEX8", "title": "MEX2018-20: Non-Invasive Vascular Testing Follow-up in Patients After Revascularization", "description": "Percentage of patients aged 18 years and older with a previous abnormal vascular study that underwent a revascularization procedure.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Med-Xpress Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MEX9", "title": "MEX2018-16: Non-Invasive Vascular Testing in Patients Diagnosed with Intermittent Claudication Who Use Cilostazol or Pentoxifylline", "description": "Percentage of patients aged 18 years and older with an abnormal non-invasive vascular study in the 12 months prior to the measurement period and who had documentation of use of Cilostazol or Pentoxifylline", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Med-Xpress Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MHAN3", "title": "Plan All Cause Readmissions", "description": "For patients 18 years of age and older, the number of acute inpatient stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission. Data are reported in the following categories:\n1. Count of Index Hospital Stays* (denominator)\n2. Count of 30-Day Readmissions (numerator)\n3. Average Adjusted Probability of Readmission", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "MyHealth Access Network", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MICS1", "title": "General Health Postoperative Improvement", "description": "Rate 1: - Change in the calculated score of a validated general health patient reported outcome survey from before to after surgery.\n\nRate 2: - The overall percentage of patients that improve their general health scores beyond a minimum threshold for each postoperative interval.\n\nInstructions: Patients who undergo a surgical procedure are asked to complete a general health outcomes survey both preoperatively and following surgery.\n\nRationale: Understanding a patient’s mental and general physical improvement as a result of surgery is an important aspect of clinical care. The general health scores that are calculated can be used to improve a specific patient’s care plan or can be analyzed retrospectively to modify overall treatment methodologies. In addition, general health scores can be used to risk adjust other, surgery specific outcomes scores that are collected. Doctors have the option of collecting a postoperative general health survey at different intervals following surgery to account for different surgery types and physician follow-up patterns.", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "CareSense", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "postsurvey", "description": "- Change in the calculated score of a validated general health patient reported outcome survey from before to after surgery." }, { "name": "overall", "description": "- The overall percentage of patients that improve their general health scores beyond a minimum threshold for each postoperative interval.\n\nInstructions: Patients who undergo a surgical procedure are asked to complete a general health outcomes survey both preoperatively and following surgery.\n\nRationale: Understanding a patient’s mental and general physical improvement as a result of surgery is an important aspect of clinical care. The general health scores that are calculated can be used to improve a specific patient’s care plan or can be analyzed retrospectively to modify overall treatment methodologies. In addition, general health scores can be used to risk adjust other, surgery specific outcomes scores that are collected. Doctors have the option of collecting a postoperative general health survey at different intervals following surgery to account for different surgery types and physician follow-up patterns." } ], "submissionMethods": [ "registry" ] }, { "measureId": "MICS2", "title": "Surgery Specific Postoperative Improvement in Pain Levels", "description": "Rate 1: - Change in the calculated pain scores of a validated surgery specific patient reported outcome survey from before to after surgery.\n\nRate 2: - The overall percentage of patients that improve their pain scores beyond a minimum threshold for each postoperative interval.\n\nInstructions: Patients who undergo a surgical procedure are asked to complete one or more surgery specific outcomes survey both preoperatively and following surgery. These outcomes surveys must contain one or more scores relevant to patient pain levels.\n\nRationale: Understanding the change in a patient’s pain levels from before to after surgery is an important aspect of clinical care. The scores that are calculated can be used to improve a specific patient’s care plan or can be analyzed retrospectively to modify overall pain treatment methodologies. Surgeons have the option of collecting the surveys at different intervals following surgery to account for different surgery types and physician follow-up patterns.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "CareSense", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "postsurvey", "description": "- Change in the calculated pain scores of a validated surgery specific patient reported outcome survey from before to after surgery." }, { "name": "overall", "description": "- The overall percentage of patients that improve their pain scores beyond a minimum threshold for each postoperative interval.\n\nInstructions: Patients who undergo a surgical procedure are asked to complete one or more surgery specific outcomes survey both preoperatively and following surgery. These outcomes surveys must contain one or more scores relevant to patient pain levels.\n\nRationale: Understanding the change in a patient’s pain levels from before to after surgery is an important aspect of clinical care. The scores that are calculated can be used to improve a specific patient’s care plan or can be analyzed retrospectively to modify overall pain treatment methodologies. Surgeons have the option of collecting the surveys at different intervals following surgery to account for different surgery types and physician follow-up patterns." } ], "submissionMethods": [ "registry" ] }, { "measureId": "MICS3", "title": "Surgery Specific Postoperative Improvement in Function Levels", "description": "Rate 1: - Change in the calculated function scores of a validated surgery specific patient reported outcome survey from before to after surgery.\n\nRate 2: - The overall percentage of patients that improve their function scores beyond a minimum threshold for each postoperative interval.\n\nInstructions: Patients who undergo a surgical procedure are asked to complete one or more surgery specific outcomes surveys both preoperatively and following surgery. These outcomes surveys must contain one or more scores relevant to patient function levels such as mobility or the ability to complete common tasks.\n\nRationale: Understanding the change in a patient’s function levels from before to after surgery is an important aspect of clinical care. The scores that are calculated can be used to improve a specific patient’s care plan or can be analyzed retrospectively to modify overall treatment methodologies. Surgeons have an option of collecting a postoperative survey at different intervals following surgery to account for different surgery types and physician follow-up patterns.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "CareSense", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "postsurvey", "description": "- Change in the calculated function scores of a validated surgery specific patient reported outcome survey from before to after surgery." }, { "name": "overall", "description": "- The overall percentage of patients that improve their function scores beyond a minimum threshold for each postoperative interval.\n\nInstructions: Patients who undergo a surgical procedure are asked to complete one or more surgery specific outcomes surveys both preoperatively and following surgery. These outcomes surveys must contain one or more scores relevant to patient function levels such as mobility or the ability to complete common tasks.\n\nRationale: Understanding the change in a patient’s function levels from before to after surgery is an important aspect of clinical care. The scores that are calculated can be used to improve a specific patient’s care plan or can be analyzed retrospectively to modify overall treatment methodologies. Surgeons have an option of collecting a postoperative survey at different intervals following surgery to account for different surgery types and physician follow-up patterns." } ], "submissionMethods": [ "registry" ] }, { "measureId": "MIRAMED16", "title": "Perioperative Pain Plan", "description": "Percentage of patients with signed documentation that a perioperative pain plan using a multimodal, narcotic sparing technique was discussed.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MiraMed", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MIRAMED17", "title": "Rate of witnessed gastric aspiration", "description": "Percentage of patients who aspirate the stomach contents into the trachea and/or lungs.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "MiraMed", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MIRAMED18", "title": "Unplanned Conversion to General Anesthesia from Regional or MAC for all scheduled cases", "description": "All patients, over the age of 18, undergoing a scheduled procedure in which the anesthesia plan is altered from a regional anesthesia or monitored anesthesia care to the administration of a general anesthetic.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MiraMed", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MIRAMED19", "title": "Onset atrial fibrillation or dysrthymia requiring unanticipated therapy", "description": "Percentage of patients, 18 or older, who exhibit sudden onset of atrial fibrillation or dysrthymia requiring intervention immediately during an otherwise unrelated event.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "MiraMed", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MIRAMED20", "title": "Perioperative cognitive function test in elderly", "description": "Percentage of patients, aged 65 or older, who are receive a cognitive function test prior to the scheduled procedure.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MiraMed", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MNCM5", "title": "Ischemic Vascular Disease Use of Aspirin or Anti-platelet Medication", "description": "The percentage of patients 18-75 years of age who had a diagnosis of ischemic vascular disease (IVD) and were on daily aspirin or anti-platelet medication, unless allowed contraindications or exceptions are present.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MN Community Measurement", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MNCM6", "title": "Diabetes A1c Control (<8.0)", "description": "The percentage of patients 18-75 years of age who had a diagnosis of type 1 or type 2 diabetes and whose most recent HbA1c during the measurement period was less than 8.0 mg/dL.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "intermediateOutcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MN Community Measurement", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MOA1", "title": "Objectifying pain and/or functionality to determine manipulative medicine efficacy with correlative treatment adjustment", "description": "Successful Reporting: Successful reporting would include a validated QVAS or similarly validated tool showing for pain and functionality show either:\n a. A two (2) point pain improvement since last clinical encounter with the treating provider or maintenance of a functional improvement greater than or equal to a six (>6).\n b. If functionality 5 or less and/or pain 7 or more, medical record documentation of treatment change or diagnostic work up is present.\n c. Failure to document these changes with continued treatment despite lessening functionality and/or increasing pain would result in measure failure.\n\n Measure explanation:\n a. Utilizes Quadruple Visual Analogue Scale (QVAS) or similarly validated tool for pain related patient encounters to assess and document efficacy, functional, clinical and/or pain improvement of at least two points (a two-point reduction to show improvement) or a functionality > 6 to show functional improvement is maintained with current treatment. Pain scale maintained between 4-6 for good control with current treatment regimen and/or a two-point improvement in pain since last visit for treatment with or without treatment adjustments. If this fails to occur provider changes technique or considers other intervention (i.e.: further diagnostics, referral, injections, prescription medication).\n b. If provider changes manipulative technique at the previous visit he/she uses QVAS at the subsequent visit to assess impact of change in technique or intervention on current pain state where patient’s pain is above a 6 on a 0-10 scale with 0 being no pain and 10 greatest pain and/or functionality is < 6 on a 0- 10 scale with 10 most and 0 least functional. Pain scale maintained between 4-6 for good control with current treatment regimen and/or a two-point improvement in pain since last visit for treatment with or without treatment adjustments. If this fails to occur provider changes technique or considers other intervention (i.e.: further diagnostics, referral, injections, prescription medication).\n\nRate 1: Percentage of patients receiving manipulative medicine with a QVAS score and treatment adjustment/maintenance for low back pain.\nRate 2: Percentage of patients receiving manipulative medicine with a QVAS score and treatment adjustment/maintenance for neck pain.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Maine Osteopathic Association in Collaboration with Patient360", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "weightedAverage", "strata": [ { "name": "back", "description": "Percentage of patients receiving manipulative medicine with a QVAS score and treatment adjustment/maintenance for low back pain." }, { "name": "neck", "description": "Percentage of patients receiving manipulative medicine with a QVAS score and treatment adjustment/maintenance for neck pain." } ], "submissionMethods": [ "registry" ] }, { "measureId": "MOA12", "title": "Treatment of spinal stenosis with manipulative medicine and alternative medicine modalities", "description": "Successful Reporting: Successful reporting would include a validated QVAS or similarly validated tool showing for pain and functionality show a two (2) point pain improvement since last clinical encounter with the treating provider or maintenance of a functional improvement greater than or equal to a six (>6). If functionality 5 or less and/or pain 7 or more, medical record documentation of treatment change or diagnostic work up is present. Failure to document these changes with continued treatment despite lessening functionality and/or increasing pain would result in measure failure.\n\n Providers would be providing manual medicine in addition to non-traditional, but literature proven alternative medicine modalities (i.e.: acupuncture) with patients who have imaging confirmed spinal stenosis (M99 ICD-10 Code).\n\n Measure explanation: Spinal stenosis typically is conservatively managed until surgical fusion or foraminotomy is necessitated based upon pain or neuropathic progression necessitating spinal fusion and/or foraminotomy. These surgeries carry risk to the patient and major expense to the system. Moreover, once a spinal fusion occurs, typically the areas above and/or below this area are fused in another 5-10 years. Avoiding the initial surgery is the only means to avoid subsequent surgeries and the associated risks and costs. Manipulative medicine combined with alternative medical therapies have been shown to improve pain and avoid surgical intervention, thus, this measure is designed to report such treatment.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Maine Osteopathic Association in Collaboration with Patient360", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MOA13", "title": "Urine Drug Screen Utilization in Pain Management and Substance Use Disorders; no less than quarterly for pain and no less than monthly for substance use disorders", "description": "Successful Reporting: Provider must document signing of a Controlled Substance Agreement (CSA) or Opiate Agreement (OA) if more than two (2) Schedule II controlled substance prescriptions are provided to a patient in a 12-month period. Understandably, prescriptions may occur in the prior reporting year as well as in the current reporting year. Documented urine drug screens (UDS) performed no less than quarterly on all pain patients and monthly for all substance use disorder patients with documented evidence of additional UDS if suspected diversion, illicit activity, or other red flags noted during the reporting year. Failure to perform the above frequency of UDS at a minimum, results in failure of this measure. Additionally, failure to increase regulatory scrutiny for red flags, diversion and/or illicit behavior (i.e.: problematic urines or pill counts) in the form of increased performance of urine drug screens via probationary periods and/or shorter prescribing periods and/or pill counts will result in measure failure.\n Measure explanation: Controlled substance agreement (CSA) or opiate agreement (OA) utilized on all patients received greater than two Schedule II controlled substance prescriptions in a 12-month period.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Maine Osteopathic Association in Collaboration with Patient360", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MOA14", "title": "Addressing anxiety in pain patients with SNRI and SSRIs and reducing/eliminating benzodiazepines for chronic anxiety", "description": "Successful Reporting: Chronic pain patients with anxiety symptoms will be provided an SNRI/SSRI prescription and not acutely given benzodiazepines as documented in the medical record and medication list. Patients with chronic pain on benzodiazepines will have those drugs serially weaned and replaced by SNRI/SSRI agents unless a defined anxiety syndrome exists, is documented by a psychiatric provider and this comorbid state is verified.\n\nMeasure explanation: Benzodiazepines are implicated in polypharmacy overdose deaths and are often prescribed for sleep or anxiety symptoms. Pain patients typically have deficits in serotonin (5-HT) and norepinephrine (NE) secondary to pain chronicity and physiologic response. NE and 5-HT block pain in the ascending spine and deficiencies are associated with increased pain and the primary presenting symptom of 5- HT deficiency is anxiety. As such, appropriate management warrants utilization of SNRI/SSRI agents in this setting in lieu of benzodiazepines.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Maine Osteopathic Association in Collaboration with Patient360", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MOA15", "title": "Weight loss in pain patients with BMI > = 30 with opiate utilization for weight related pain conditions rather than opiate dose escalation for improved pain control", "description": "Successful Reporting: In chronic pain patients with weight related or weight exacerbated pain conditions (i.e.: DJD, DDD, Hip Pain/OA, Knee Pain/OA, Foot/Ankle Pain/OA, Pes Planus related plantar fasciitis) BMI will be documented and monitored at scheduled visits with serial reduction in BMI over the reporting period with correlative dose reduction (24 hour MME) of opiate/opioid therapy if no BMI reduction occurs as outlined below.\n\n Measure explanation: Pain conditions that can be treated definitively to avoid or cease opiate/opioid utilization should engage such treatment. Obesity, if causally related to pain, disease progression, and/or the major etiologic event must be addressed. Dose escalation for BMI escalation or maintenance is harmful and potentially dangerous to patients categorized as obese due to respiratory suppression and opiate/opioid related systemic endocrine dysfunction. Obesity is treatable. Pain medication may be needed initially help patients exercise and function to address pain in both weight bearing and non-weight bearing joints affected by obesity. However, weight reduction should eventually reduce opiate need and dosing if monitored, addressed and treated as part of comprehensive pain management.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Maine Osteopathic Association in Collaboration with Patient360", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MOA2", "title": "Appropriate use of advanced imaging by ordering provider with glucocorticoid management to spare motor neuron loss when physical findings suggest neuropathic etiology", "description": "Successful Reporting: Successful reporting would include >80% of encounters where advanced imaging was done only subsequent to an Evaluation and Management (E&M) encounter where the physical examination included appropriate and focal neurologic and/or musculoskeletal evaluations that support the imaging study(ies) being ordered. Correlative documentation of an oral corticosteroid (i.e. prednisone) prescription given in the face of pending advanced diagnostic imaging (i.e. CT or MRI) when documented symptoms or physical findings warrant utilization AND no contraindications to medications exist. Successful reporting of this measure would be the aforementioned medical record documentation with and at the time of the CPT/ICD combinations noted in the reporting year.\n\n Measure explanation: Neurologic examination and/or focused musculoskeletal examination relative to symptomatic complaints documented prior to ordering MRI or CT Scan of neck or lumbar/lumbosacral spine for low back pain complaint. Corticosteroids/glucocorticoids given for symptomatic radicular pain and/or paresthesias with neurologic examination positive or equivocal, while advanced diagnostic imaging (i.e.: CT or MRI) is pending.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Maine Osteopathic Association in Collaboration with Patient360", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MOA7", "title": "Appropriate controlled substance prescribing (definitive diagnosis(es)) via adherence to Controlled Substance Agreements (CSA) or (OA's) with corrective action taken for pain and/or substance use disorder patients when violations occur", "description": "Successful Reporting:\n a. Documentation of definitive pathology (e.g., imaging, surgical report, serology, provider referral for addiction/substance use disorder, etc.) to warrant chronic pain and/or buprenorphine/naloxone medication chronically.\n b. Provider must document signing of a Controlled Substance (CSA) or Opiate Agreement (OA) if more than two (2)Schedule II controlled substance prescriptions are provided to a patient in a 12-month period. Understandably, prescriptions may occur in the prior reporting year as well as in the current reporting year.\n c. For all patients violating existing CSA/OA, such violations are documented with correlative adjustments in treatment (e.g.: shorter duration prescriptions (2 week to 4 week), increased frequency of urine drug screens (quarterly to monthly), random pill counts, more frequent visits, or dose reduction.\n Measure explanation: Chronic Pain medication prescribed (prescribed for greater than one week or more than twice a year) only after a diagnosis and medical or surgical plan has been implemented. CSA or OA followed and, if actionable violation (i.e.: Urine Drug Screen inappropriate, pill counts off, multiple providers prescribing, polypharmacy, etc.) corrective action taken (i.e.: probation, escalated use of Urine Drug Screens, shorter prescriptions intervals, termination of controlled prescribing or similar actions) as result of the CSA/OA violation.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Maine Osteopathic Association in Collaboration with Patient360", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MSSIC1", "title": "Pre-surgical screening for depression", "description": "The measure reflects the percent of surgical cases that received a formal pre-surgical screening for depression. MSSIC uses the PHQ-2 brief screening instrument", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Michigan Spine Surgery Improvement Collaborative", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MSSIC10", "title": "Percent of patients achieving MCID for pain-related disability (ODI/NDI)", "description": "The measure reflects the percent of patients receiving spine surgery who report an improvement in pain-related disability that is equal to, or greater than, the standard \"Minimum Clinically Important Difference\" for the specific measures used in MSSIC to assess back or neck pain. The MCID values are standard values (e.g., 1.75 points or more on a 0-10 rating scale) obtained from published articles, and are specific to spine surgery. The ideal value for the measure is 100% (all patients got better), but actual values are lower than that and vary significantly from hospital to hospital and surgeon to surgeon.\n\n Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon. Although it is a rare situation, patients with baseline scores so low as to not allow for an improvement larger than the MCID are excluded from the rate calculation. (Patients with myelopathy as an indication for surgery, for example, may not have pain.)", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Michigan Spine Surgery Improvement Collaborative", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MSSIC11", "title": "Percent Satisfied with Result", "description": "The measure reflects the percent of patients receiving spine surgery who report being satisfied with the result of surgery, either in terms of having received the benefit they wanted and expected, or having achieved enough benefit that they would be willing to do the procedure again to achieve the same benefit.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Michigan Spine Surgery Improvement Collaborative", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MSSIC12", "title": "Risk-adjusted rate of hospital readmission", "description": "The measure reflects the percent of patients receiving spine surgery who were readmitted to a hospital within 90 days of surgery. Planned \"readmissions\" for two-stage procedures or other reasons are not counted. Rates are reported for all-cause readmissions, although the registry allows for separate analysis of spine-related vs. unrelated readmissions.\n\nRates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Michigan Spine Surgery Improvement Collaborative", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MSSIC13", "title": "Risk-adjusted rate of surgical site infection", "description": "The measure reflects the percent of patients receiving spine surgery who had a clinically significant surgical site infection following surgery, requiring treatment.\n\n Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Michigan Spine Surgery Improvement Collaborative", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MSSIC14", "title": "Risk-adjusted rate of urinary retention", "description": "The measure reflects the percent of patients receiving spine surgery who had a clinically significant issue of urinary retention (residual urine in bladder after voiding, or inability to void) in the immediate post-surgical period.\n\nRates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Michigan Spine Surgery Improvement Collaborative", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MSSIC16", "title": "Percent of patients achieving MCID for myelopathy", "description": "The measures reflects the percent of patients receiving cervical spine surgery who report an improvement in myelopathy that is equal to, or greater than, the standard \"Minimum Clinically Important Difference\" for the specific measure used in MSSIC to assess myelopathy (the mJOA scale). The MCID value is a standard value obtained from published articles, and is specific to spine surgery. The ideal value for the measure is 100% (all patients got better), but actual values are lower than that and vary significantly from hospital to hospital and surgeon to surgeon.\n\n Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon. Although it is a rare situation, patients with baseline scores so low as to not allow for an improvement larger than the MCID are excluded from the rate calculation. (Patients with myelopathy as an indication for surgery, for example, may not have pain.)", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Michigan Spine Surgery Improvement Collaborative", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MSSIC6", "title": "Percent same-day ambulation", "description": "The measure reflects the percent of patients receiving spine surgery for whom there is medical record evidence of ambulation (actual movement out of the bed, not just feet dangling out of bed) on the day of surgery. Analysis of MSSIC data in 2016 showed the early ambulation is a significant protective factor for a variety of complications, and that there is currently significant variability among hospitals and surgeons in terms of the percent of patients who do have ambulation on the day of surgery.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Michigan Spine Surgery Improvement Collaborative", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MSSIC7", "title": "Rate of use of Pre-op skin preparation/wash", "description": "The measure reflects the percent of patients receiving spine surgery for whom there is medical record evidence of use of evidence-based interventions to prevent surgical site infection (SSI). SSI is a relatively rare but serious complication of surgery, and is preventable to some extent by specific pre-surgical site preparation done by patients the day before surgery. Data from MSSIC suggests significant variability among surgeons and among hospitals in terms of the percent of patients for whom a formal pre-surgical wash preparation is used.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Michigan Spine Surgery Improvement Collaborative", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MSSIC8", "title": "Percent of patients achieving MCID for back or neck pain", "description": "The measure reflects the percent of patients receiving spine surgery who report an improvement in back or neck pain that is equal to, or greater than, the standard \"Minimum Clinically Important Difference\" for the specific measures used in MSSIC to assess back or neck pain. The MCID values are standard values (e.g., 1.75 points or more on a 0-10 rating scale) obtained from published articles, and are specific to spine surgery. The ideal value for the measure is 100% (all patients got better), but actual values are lower than that and vary significantly from hospital to hospital and surgeon to surgeon.\n\n Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon. Although it is a rare situation, patients with baseline scores so low as to not allow for an improvement larger than the MCID are excluded from the rate calculation. (Patients with myelopathy as an indication for surgery, for example, may not have pain.)", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Michigan Spine Surgery Improvement Collaborative", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MSSIC9", "title": "Percent of patients achieving MCID for leg or arm pain", "description": "The measure reflects the percent of patients receiving spine surgery who report an improvement in leg or arm pain that is equal to, or greater than, the standard \"Minimum Clinically Important Difference\" for the specific measures used in MSSIC to assess back or neck pain. The MCID values are standard values (e.g., 1.75 points or more on a 0-10 rating scale) obtained from published articles, and are specific to spine surgery. The ideal value for the measure is 100% (all patients got better), but actual values are lower than that and vary significantly from hospital to hospital and surgeon to surgeon.\n\n Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon. Although it is a rare situation, patients with baseline scores so low as to not allow for an improvement larger than the MCID are excluded from the rate calculation. (Patients with myelopathy as an indication for surgery, for example, may not have pain.)", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Michigan Spine Surgery Improvement Collaborative", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MUSIC1", "title": "Prostate Biopsy Antibiotic Compliance", "description": "Compliance with AUA best practices for antibiotic prophylaxis for transrectal ultrasound-guided (TRUS) biopsy", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MUSIC10", "title": "Prostate Cancer: Confirmation Testing in low risk AS eligible patients", "description": "Percentage of low risk patients that are eligible for active surveillance who receive confirmation testing within 6 months of diagnosis", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MUSIC11", "title": "Prostate Cancer: Follow-Up Testing for patients on active surveillance for at least 30 months", "description": "Percentage of patients on active surveillance that have ≥ 2 tumor burden reassessments and 3 PSA tests in first 30 months since diagnosis", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MUSIC3", "title": "Prostate Cancer: Avoidance of Overuse of CT Scan for Staging Low Risk Prostate Cancer Patients", "description": "Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a CT scan performed at any time since diagnosis of prostate cancer", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MUSIC4", "title": "Prostate Cancer: Active Surveillance/Watchful Waiting for Low Risk Prostate Cancer Patients", "description": "Proportion of patients with low-risk prostate cancer receiving active surveillance or watchful waiting", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MUSIC5", "title": "Prostate Cancer: Radical Prostatectomy Cases LOS", "description": "Percentage of radical prostatectomy cases with a length of stay > 2 days", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MUSIC9", "title": "Prostate Biopsy: Repeat Biopsy for Patients with Atypical Small Acinar Proliferation (ASAP)", "description": "Proportion of patients undergoing a repeat prostate biopsy within 12 months of their initial biopsy in the registry as a result of a finding of atypical small acinar proliferation (ASAP) as per the NCCN guidelines.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NHBPC10", "title": "Telephone Contact, Virtual, or In-person Visit Within 48 Hours of Hospital Discharge of Home-Based Primary Care and Palliative Care Patients", "description": "Percentage of actively enrolled home-based primary care and palliative care patients who had a telephone contact, virtual, or in-person visit within 48 hours of hospital discharge.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Home-Based Primary Care & Palliative Care Registry in Collaboration with the American Academy of Home Care Medicine, Powered by Premier", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NHBPC13", "title": "Interdisciplinary Team Assessment for Home-Based Primary care and Palliative Care Patients", "description": "Percentage of newly enrolled and active home-based primary care and palliative care patients who were discussed by an interdisciplinary team** at enrollment. **Interdisciplinary team must include, at minimum, the following disciplines: MD or NP or PA, nursing, and social work.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Home-Based Primary Care & Palliative Care Registry in Collaboration with the American Academy of Home Care Medicine, Powered by Premier", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NHBPC14", "title": "Cognitive Assessment for Home-Based Primary Care and Palliative Care Patients", "description": "Percentage of actively enrolled home-based primary care and palliative care patients who received an assessment of their cognitive ability.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Home-Based Primary Care & Palliative Care Registry in Collaboration with the American Academy of Home Care Medicine, Powered by Premier", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NHBPC15", "title": "A Functional Assessment (Basic and Instrumental Activities of Daily Living [ADL]) for Home-Based Primary Care and Palliative Care Patients (Multiperformance Measure)", "description": "Percentage of actively enrolled home-based primary care and palliative care patients who received basic ADL assessments and IADL assessments at enrollment and annually.\n\nThis measure will be calculated with three rates:\n\nRate 1: Percentage of patients who received a basic ADL assessment\nRate 2: Percentage of patients who received an IADL assessment\nRate 3: Percentage of patients who received both a basic ADL and IADL assessment (overall rate)", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Home-Based Primary Care & Palliative Care Registry in Collaboration with the American Academy of Home Care Medicine, Powered by Premier", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "ADL", "description": "Percentage of patients who received a basic ADL assessment" }, { "name": "IADL", "description": "Percentage of patients who received an IADL assessment" }, { "name": "overall", "description": "Percentage of patients who received both a basic ADL and IADL assessment (overall rate)" } ], "submissionMethods": [ "registry" ] }, { "measureId": "NHBPC16", "title": "Patient Reported Outcome for Home-Based Primary Care and Palliative Care Practices", "description": "Percentage of actively enrolled home-based primary and palliative care patients who report that their provider is caring and inspires trust.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Home-Based Primary Care & Palliative Care Registry in Collaboration with the American Academy of Home Care Medicine, Powered by Premier", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NHBPC17", "title": "Screening for Depression and Follow-up Plan in Home-Based Primary Care and Palliative Care Patients", "description": "Percentage of actively enrolled home-based primary care and palliative care patients who were screened for the presence of depression symptoms at enrollment and annually AND if positive, have a treatment plan for depression documented on the date of the positive screen.", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Home-Based Primary Care & Palliative Care Registry in Collaboration with the American Academy of Home Care Medicine, Powered by Premier", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NHBPC2", "title": "Alcohol Problem Use Assessment for Home-Based Primary Care and Palliative Care Patients", "description": "Percentage of newly enrolled and active home-based primary care and palliative care patients who were assessed for a problem with alcohol use at enrollment.", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Home-Based Primary Care & Palliative Care Registry in Collaboration with the American Academy of Home Care Medicine, Powered by Premier", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NHBPC6", "title": "Screen for Risk of Future Fall for Home-Based Primary Care and Palliative Care Patients", "description": "Percentage of actively enrolled home-based primary care and palliative care patients who were screened for risk of future fall at enrollment and annually.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Home-Based Primary Care & Palliative Care Registry in Collaboration with the American Academy of Home Care Medicine, Powered by Premier", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NHBPC7", "title": "Delirium Assessment in Home-Based Primary Care and Palliative Care Patients: Medication List Reviewed & Offending Medications Discontinued (Multiperformance-Rate Measure)", "description": "Percentage of actively enrolled home-based primary care and palliative care patients with new diagnosis of altered mental status, delirium, or new or unexpected cognitive decline whose medication lists were reviewed for possible offending medications and whose use of medications was discontinued or justified. This measure will be calculated with two rates:\n\nRate 1: Percentage of patients whose medications lists were reviewed for possible offending medications.\nRate 2: Percentage of patients with offending medications whose use of offending medications was discontinued or justified.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Home-Based Primary Care & Palliative Care Registry in Collaboration with the American Academy of Home Care Medicine, Powered by Premier", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "reviewed", "description": "Percentage of patients whose medications lists were reviewed for possible offending medications." }, { "name": "overall", "description": "Percentage of patients with offending medications whose use of offending medications was discontinued or justified." } ], "submissionMethods": [ "registry" ] }, { "measureId": "NHBPC9", "title": "Referral to Hospice for Appropriate Home-Based Primary Care and Palliative Care Patients", "description": "Percentage of actively enrolled home-based primary care and palliative care patients with a prognosis of 6 months or less who were offered referral to hospice.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Home-Based Primary Care & Palliative Care Registry in Collaboration with the American Academy of Home Care Medicine, Powered by Premier", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NHCR4", "title": "NHCR4: Repeat screening or surveillance colonoscopy recommended within one year due to inadequate/poor bowel preparation", "description": "Percentage of patients recommended for repeat screening or surveillance colonoscopy within one year or less due to inadequate/poor bowel preparation quality", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "New Hampshire Colonoscopy Registry (NHCR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NHCR5", "title": "NHCR5: Repeat colonoscopy recommended due to piecemeal resection", "description": "Percentage of exams with polyps removed by piecemeal excision who are told to return in appropriate interval (<=1 year)", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "New Hampshire Colonoscopy Registry (NHCR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NHCR9", "title": "Appropriate indication for colonoscopy", "description": "percentage of colonoscopies performed for a clinically appropriate indication", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "New Hampshire Colonoscopy Registry (NHCR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NIPM10", "title": "COMMUNICATING CONCURRENT OPIOID AND BENZODIAZEPINE PRESCRIBING TO OTHER PRESCRIBERS", "description": "Percentage of patients 18 years of age and older who are prescribed opioids and have a letter or other communication sent to another clinician who is prescribing benzodiazepines. This measure is reported by the clinician who prescribes opioids to a patient already taking benzodiazepines. Communication must occur at the time of initial opioid prescribing and following any gaps in prescribing of greater than 6 months, or once per reporting year for patients on continuous chronic opioid and benzodiazepine therapy.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NIPM11", "title": "PATIENT COUNSELING REGARDING RISKS OF CO-PRESCRIBED OPIOIDS AND BENZODIAZEPINES", "description": "Percentage of patients 18 years of age and older who are prescribed both opioids and benzodiazepines and receive either written or verbal education regarding the risks of concurrent opioid and benzodiazepine use. Education and counseling must occur at the time of initial co-prescribing, and following any gap of greater than 6 months of co-prescribing, or at least once per reporting period for patients taking chronic concurrent opioid and benzodiazepine therapy.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NIPM12", "title": "FUNCTIONAL STATUS ASSESSMENT FOR SPINAL CORD STIMULATOR IMPLANTATION", "description": "Percentage of patients 18 years of age and older who undergo spinal cord stimulator implantation who completed baseline and follow-up patient-reported functional status assessments, and achieved at least a 10% improvement in functional status score from baseline. Follow-up functional assessment must be completed within 90 days following the procedure.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NIPM13", "title": "FUNCTIONAL STATUS ASSESSMENT FOR LUMBAR MEDIAL BRANCH RADIOFREQUENCY ABLATION", "description": "Percentage of patients 18 years of age and older with lumbar medial branch radiofrequency ablation who completed baseline and follow-up patient-reported functional status assessments, and achieved at least a 10% improvement in functional status score from baseline. Follow-up functional assessment must be completed within 90 days following the procedure.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NIPM14", "title": "FUNCTIONAL STATUS ASSESSMENT FOR CERVICAL MEDIAL BRANCH RADIOFREQUENCY ABLATION", "description": "Percentage of patients 18 years of age and older with cervical medial branch radiofrequency ablation who completed baseline and follow-up patient-reported functional status assessments, and achieved at least a 10% improvement in functional status score from baseline. Follow-up functional assessment must be completed within 90 days following the procedure.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NIPM15", "title": "REDUCTION IN PATIENT REPORTED PAIN FOLLOWING SPINAL CORD STIMULATOR IMPLANTATION FOR FAILED BACK SURGERY SYNDROME", "description": "Measurement of reduction in pain as reported by patients aged 18 years and older following implantation of a spinal cord stimulator and implantable pulse generator for the indication of failed back surgery syndrome", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "NIPM16", "title": "REDUCTION IN PATIENT REPORTED PAIN FOLLOWING LUMBAR MEDIAL BRANCH RADIOFREQUENCY ABLATION", "description": "REDUCTION IN PATIENT REPORTED PAIN FOLLOWING LUMBAR MEDIAL BRANCH RADIOFREQUENCY ABLATION", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "NIPM17", "title": "REDUCTION IN PATIENT REPORTED PAIN FOLLOWING CERVICAL/THORACIC MEDIAL BRANCH RADIOFREQUENCY ABLATION", "description": "Measurement of reduction in pain as reported by patients aged 18 years and older following cervical/thoracic medial branch radiofrequency ablation", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "NIPM4", "title": "APPROPRIATE PATIENT SELECTION FOR DIAGNOSTIC FACET JOINT PROCEDURES", "description": "Measurement of proportion of patients aged 18 years or older meeting appropriate patient selection criteria for diagnostic facet joint procedures.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NIPM8", "title": "AVOIDING EXCESSIVE USE OF EPIDURAL INJECTIONS IN MANAGING CHRONIC PAIN ORIGINATING IN THE CERVICAL AND THORACIC SPINE", "description": "Measurement of percentage of patients aged 18 years and older receiving therapeutic cervical/thoracic epidural injections that do not receive an excessive number of injections during the measurement period.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NIPM9", "title": "AVOIDING EXCESSIVE USE OF THERAPEUTIC FACET JOINT INTERVENTIONS IN MANAGING CHRONIC CERVICAL AND THORACIC SPINAL PAIN", "description": "Measurement of percentage of patients aged 18 years and older receiving cervical/thoracic facet joint interventions that do not receive an excessive number of procedures during the measurement period, based on the recommendations of the American Society of Interventional Pain Physicians, multiple Medicare carriers, or private insurers.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NJIISMD1", "title": "Critical Result: Pulmonary Embolism", "description": "Efficiency of reporting Critical Result: Pulmonary Embolism diagnosed on radiology exams", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD, LLC in collaboration with SunCoast RHIO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NJIISMD10", "title": "Critical Result: Ruptured Ectopic Pregnancy", "description": "Efficiency of reporting Critical Result: Ruptured ectopic pregnancy diagnosed on radiology exams", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD, LLC in collaboration with SunCoast RHIO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NJIISMD11", "title": "Critical Result: New Deep Venous Thrombosis (DVT)", "description": "Efficiency of reporting Critical Result: New DVT diagnosed on radiology exams", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD, LLC in collaboration with SunCoast RHIO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NJIISMD12", "title": "Critical Result: Ectopic Pregnancy", "description": "Efficiency of reporting Critical Result: Ectopic Pregnancy diagnosed on radiology exams", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD, LLC in collaboration with SunCoast RHIO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NJIISMD17", "title": "Result Requiring Follow Up Protocol", "description": "Timeliness of notification in cases of diagnostic exams when there is a recommendation to obtain a follow up exam.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD, LLC in collaboration with SunCoast RHIO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NJIISMD19", "title": "Critical Result: Cord Compression", "description": "Efficiency of reporting Critical Result: Cord Compression diagnosed on radiology exams", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD, LLC in collaboration with SunCoast RHIO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NJIISMD2", "title": "Critical Result: ICH", "description": "Efficiency of reporting Critical Result: ICH diagnosed on radiology exams", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD, LLC in collaboration with SunCoast RHIO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NJIISMD20", "title": "Critical Result: CTA of GI bleed", "description": "Efficiency of reporting Critical Result: GI Bleed diagnosed on radiology exams", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD, LLC in collaboration with SunCoast RHIO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NJIISMD21", "title": "Critical Result: Positive bleeding scan", "description": "Efficiency of reporting Critical Result: Positive Bleeding Scan", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD, LLC in collaboration with SunCoast RHIO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NJIISMD22", "title": "Critical Result: Acute Ocular injury", "description": "Efficiency of reporting Critical Result: Acute Ocular Injury diagnosed on radiology exams", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD, LLC in collaboration with SunCoast RHIO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NJIISMD3", "title": "Critical Result: Aortic Dissection", "description": "Efficiency of reporting Critical Result: Aortic Dissection diagnosed on radiology exams", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD, LLC in collaboration with SunCoast RHIO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NJIISMD8", "title": "Critical Result: Occlusive Intracranial Stroke", "description": "Efficiency of reporting Critical Result: Occlusive intracranial stroke diagnosed on radiology exams", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD, LLC in collaboration with SunCoast RHIO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NJIISMD9", "title": "Critical Result: Placental abruption", "description": "Efficiency of reporting Critical Result: Placental abruption diagnosed on radiology exams", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD, LLC in collaboration with SunCoast RHIO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NNEPTN1", "title": "Substance Use Screening", "description": "This measure produces two rates of substance use screening: Rate 1: Percentage of patients age > 12 and <18 years screened for substance use using an age appropriate evidence based standardized tool within the measurement year. Rate 2: Percentage of patients age 18 years and older screened for substance use using an evidence based standardized tool within the measurement year", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Northern New England Practice Transformation Network in Collaboration with Mingle Analytics", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "weightedAverage", "strata": [ { "name": "12to18", "description": "Percentage of patients age > 12 and <18 years screened for substance use using an age appropriate evidence based standardized tool within the measurement year." }, { "name": "18", "description": "Percentage of patients age 18 years and older screened for substance use using an evidence based standardized tool within the measurement year" } ], "submissionMethods": [ "registry" ] }, { "measureId": "NNEPTN2", "title": "Transforming Clinical Practice Initiative Common Measure Name: Substance Use Screening and Intervention Composite", "description": "Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for tobacco use, unhealthy alcohol use, nonmedical prescription drug use, and illicit drug use AND who received an intervention for all positive screening results. The following two measures are encompassed in this composite measure: NQF 2152, Preventive Care and Screening: Unhealthy Alcohol Use – Screening and Brief Counseling and NQF 0028 Preventive Care and Screening: Tobacco Use – Screening and Intervention.", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Northern New England Practice Transformation Network in Collaboration with Mingle Analytics", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NNEPTN3", "title": "Transforming Clinical Practice Initiative Common Measure Name: TCP01: Documentation of a Comprehensive Health and Life Plan Developed Collaboratively by the Patient and the Health Professional Team", "description": "Documentation of a comprehensive health and life plan developed collaboratively and holistically with bi-directional communications by the patient and the health team. The plan needs to be documented in the health record and easily accessible to the patient. The health and life plan encompasses all of the following elements: 1. Patient health concerns, life and health goals, behavioral/mental health , coping mechanisms, and self-management plans determined by: a. Patient communication b. Health professional assessments; 2. Identify gaps in the achievement of health and life plan; 3. Health status evaluations, interventions, and outcomes; 4. Action plans: a. An action plan is completed by a health professional in collaboration with the patient and includes specific directions for the management of all health and life goals. 5. Medication Management; 6. Identify community/social services and family support; 7. Advanced directives", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Northern New England Practice Transformation Network in Collaboration with Mingle Analytics", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NOF12", "title": "Median Time to Pain Management for Long Bone Fracture", "description": "Median time from emergency department arrival to time of initial oral or parenteral pain medication administration for emergency department patients with a principal diagnosis of long bone fracture (LBF).", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "NOF and NBHA Quality Improvement Registry - Powered by Premier, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "NOF13", "title": "Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older", "description": "Percentage of patients aged 50 years or older with fracture of the hip, spine or distal radius that had a central DXA measurement ordered or performed or pharmacologic therapy prescribed", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "NOF and NBHA Quality Improvement Registry - Powered by Premier, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NOF6", "title": "Hip Fracture Mortality Rate (IQI 19)", "description": "Percentage of patients aged 65 and older with hip fracture as a principal diagnosis (excluding perioprosthetic fracture discharges, obstetric discharges, and transfers to another hospital) who expired during the hospital stay", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "NOF and NBHA Quality Improvement Registry - Powered by Premier, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NOF7", "title": "Osteoporosis: percentage of patients, any age, with a diagnosis of osteoporosis who are either receiving both calcium & vitamin D intake, & exercise at least once within 12 months.", "description": "Percentage of patients, regardless of age, with a diagnosis of osteoporosis who are either receiving both calcium and vitamin D or had documented counseling regarding both calcium and vitamin D intake, and exercise at least once within 12 months", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "NOF and NBHA Quality Improvement Registry - Powered by Premier, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPA11", "title": "Unplanned Readmission Following Spine Procedure within the 30-Day Postoperative Period", "description": "Percentage of patients aged 18 years and older who had any unplanned readmission for spine-related procedure within the 30-day postoperative period", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Quality Outcomes Database (QOD) - NeuroPoint Alliance, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPA12", "title": "Selection of Prophylactic Antibiotic Prior to Spine Procedure", "description": "Percentage of patients aged 18 years and older undergoing an index spine-related procedure with the indications for prophylactic antibiotics who had an order for antimicrobial prophylaxis", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Quality Outcomes Database (QOD) - NeuroPoint Alliance, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPA14", "title": "Medicine Reconciliation Following Spine Related Procedure", "description": "Percentage of patients aged 18 years and older undergoing spine-related procedures, discharged from operative facility, and seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, who had a reconciliation of the discharge medications with the current medication list documented in the outpatient medical record", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Quality Outcomes Database (QOD) - NeuroPoint Alliance, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPA15", "title": "Risk Assessment for Elective Spine Procedure", "description": "Percentage of patients who underwent elective therapy(-ies) for spine-related disorders with documentation of risk factor assessment by their treatment team prior to therapy and who received personal discussion of those documented risks with the healthcare provider", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Quality Outcomes Database (QOD) - NeuroPoint Alliance, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPA16", "title": "Depression and Anxiety Assessment Prior to Spine-Related Therapies", "description": "Percentage of patients aged 18 years and older with documentation of depression and/or anxiety assessment through discussion with the patient including the use of a standardized assessment tool prior to index therapy(-ies) for treatment of spine-related pain symptoms", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Quality Outcomes Database (QOD) - NeuroPoint Alliance, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPA17", "title": "Narcotic Pain Medicine Management Following Elective Spine Procedure", "description": "Percentage of patients aged 18 years and older who underwent elective therapies for spine-related pain who were assessed for narcotic use/requirements at the time of discharge. The performance measure was met if the patient 1) was not receiving narcotics post-discharge or 2) was receiving narcotics for pain for less than 2 weeks post-discharge or 3) was expected to require narcotics for more than 2 weeks after the index procedure and a narcotic use management plan was documented", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Quality Outcomes Database (QOD) - NeuroPoint Alliance, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPA18", "title": "Smoking Assessment and Cessation Coincident With Spine-Related Therapies", "description": "Percentage of patients aged 18 years and older who were assessed for tobacco use prior to spine-related therapy(-ies) and who received cessation counseling intervention if identified as a tobacco user.", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Quality Outcomes Database (QOD) - NeuroPoint Alliance, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPA19", "title": "Body Mass Assessment and Follow-up Coincident With Spine-Related Therapies", "description": "Percentage of patients aged 18 years and older with a weight and height recorded in the medical record at the time of initial evaluation and/or treatment of spine-related disorder and, if the most recent body mass index (BMI) is outside of normal parameters (BMI  23 and < 30 for patients 65 years and older; BMI ≥ 18.5 and < 25 for patients 18-64 years of age), a follow-up plan is documented (example: “Patient referred to nutrition counseling for BMI above normal parameters”).", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Quality Outcomes Database (QOD) - NeuroPoint Alliance, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPA20", "title": "Unhealthy Alcohol Use Assessment Coincident With Spine Care", "description": "Percentage of patients aged 18 years and older being treated for spine-related disorders who were assessed for unhealthy alcohol use prior to index therapy(-ies) for treatment of spine-related pain symptoms", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Quality Outcomes Database (QOD) - NeuroPoint Alliance, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPA23", "title": "Spine/Extremity Pain Assessment", "description": "Percentage of patients aged 18 years and older with documentation of a pain assessment through discussion with the patient including the use of a standardized back or neck pain tool(s) AND/OR leg or arm pain tool(s) at baseline and 3 months following index therapy(-ies) for treatment of spine-related pain symptoms with at least 10% improvement in the pain status from the baseline and documentation of follow-up plan. This measure will be calculated with 2 performance rates:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in pain status after Follow-up/Patient population with Follow-up.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Quality Outcomes Database (QOD) - NeuroPoint Alliance, Inc.", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "baseline", "description": "Patient population with Follow-up/Patient population with baseline" }, { "name": "overall", "description": "Patient population with improvement in pain status after Follow-up/Patient population with Follow-up." } ], "submissionMethods": [ "registry" ] }, { "measureId": "NPA3", "title": "Functional Outcome Assessment for Spine Intervention", "description": "Percentage of patients aged 18 years and older undergoing index spine therapy (-ies) who completed baseline and 3-month follow-up (patient-reported) functional outcome assessment, with at least 10% improvement in the functional status scaled score from the baseline. This measure will be calculated with 2 performance rates:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in functional status after Follow-up/Patient population with Follow-up.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Quality Outcomes Database (QOD) - NeuroPoint Alliance, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "baseline", "description": "Patient population with Follow-up/Patient population with baseline" }, { "name": "overall", "description": "Patient population with improvement in functional status after Follow-up/Patient population with Follow-up." } ], "submissionMethods": [ "registry" ] }, { "measureId": "NPA4", "title": "Quality-of-Life Assessment for Spine Intervention", "description": "Percentage of patients aged 18 years and older undergoing index spine therapy(-ies) who completed baseline and 3-month follow-up (patient-reported) quality-of-life assessment, with an improvement in the quality of life status from baseline. This measure will be calculated with 2 performance rates:\n1) Rate 1: Patient population with Follow-up/Patient population with baseline\n2) Rate 2: Patient population with improvement in quality of life status after Follow-up/Patient population with Follow-up.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Quality Outcomes Database (QOD) - NeuroPoint Alliance, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "baseline", "description": "Patient population with Follow-up/Patient population with baseline\n2)" }, { "name": "overall", "description": "Patient population with improvement in quality of life status after Follow-up/Patient population with Follow-up." } ], "submissionMethods": [ "registry" ] }, { "measureId": "NPA5", "title": "Patient Satisfaction With Spine Care", "description": "Percentage of patients aged 18 years and older undergoing index spine therapy(-ies) who completed 3-month follow-up (patient-reported) satisfaction with care assessment. Satisfaction will be reported as % of patients reporting satisfaction with procedure. This measure will be calculated with 2 performance rates:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in satisfaction with care status after Follow-up/Patient population with Follow-up.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Quality Outcomes Database (QOD) - NeuroPoint Alliance, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "baseline", "description": "Patient population with Follow-up/Patient population with baseline" }, { "name": "overall", "description": "Patient population with improvement in satisfaction with care status after Follow-up/Patient population with Follow-up." } ], "submissionMethods": [ "registry" ] }, { "measureId": "NPA6", "title": "Spine-Related Procedure Site Infection", "description": "Percentage of patients aged 18 years and older who had a surgical-site infection (SSI) within 30 days of the index spine procedure.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Quality Outcomes Database (QOD) - NeuroPoint Alliance, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPAGSC10", "title": "Spine/Extremity Pain Assessment", "description": "Percentage of patients aged 18 years and older with documentation of a pain assessment through discussion with the patient including the use of a standardized back or neck pain tool(s)AND/ OR Leg or arm pain tool(s) at baseline and 2 +/-1 month following initial assessment and therapy(-ies) for treatment of spine-related pain symptoms and documentation of follow-up plan. Two rates can be reported for baseline and follow-up:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in status after Follow-up/Patient population with baseline", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAPM&R's Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "overall", "description": "Patient population with Follow-up/Patient population with baseline" }, { "name": "improvement", "description": "Patient population with improvement in status after Follow-up/Patient population with baseline" } ], "submissionMethods": [ "registry" ] }, { "measureId": "NPAGSC3", "title": "Functional Outcome Assessment for Spine Intervention", "description": "Percentage of patients aged 18 years and older undergoing spine therapy(-ies) who completed baseline and 2 +/- 1 month follow-up (patient-reported) functional outcome assessment. Two rates can be reported for baseline and follow-up:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in status after Follow-up/Patient population with baseline", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAPM&R's Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "overall", "description": "Patient population with Follow-up/Patient population with baseline" }, { "name": "improvement", "description": "Patient population with improvement in status after Follow-up/Patient population with baseline" } ], "submissionMethods": [ "registry" ] }, { "measureId": "NPAGSC4", "title": "Quality-of-Life Assessment for Spine Intervention", "description": "Percentage of patients aged 18 years and older undergoing spine therapy(-ies) who completed baseline and 2 +/- 1 month follow-up (patient-reported) quality-of-life assessment. Two rates can be reported for baseline and follow-up:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in status after Follow-up/Patient population with baseline", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAPM&R's Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "overall", "description": "Patient population with Follow-up/Patient population with baseline" }, { "name": "improvement", "description": "Patient population with improvement in status after Follow-up/Patient population with baseline" } ], "submissionMethods": [ "registry" ] }, { "measureId": "NPAGSC5", "title": "Patient Satisfaction with Spine Care", "description": "Percentage of patients aged 18 years and older undergoing spine therapy(-ies) who completed 2 +/- 1 month follow-up (patient-reported) satisfaction with care assessment. Two rates can be reported for baseline and follow-up:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in status after Follow-up/Patient population with baseline", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAPM&R's Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "overall", "description": "Patient population with Follow-up/Patient population with baseline" }, { "name": "improvement", "description": "Patient population with improvement in status after Follow-up/Patient population with baseline" } ], "submissionMethods": [ "registry" ] }, { "measureId": "NPAGSC6", "title": "Depression and Anxiety Assessment Prior to Spine-Related Therapies", "description": "Percentage of patients aged 18 years and older with documentation of depression and/or anxiety assessment through discussion with the patient including the use of a standardized assessment tool prior to therapy(-ies) for treatment of spine-related pain symptoms.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAPM&R's Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPAGSC7", "title": "Narcotic Pain Medicine Management Prior to and Following Spine Therapy", "description": "Percentage of patients aged 18 years and older with documentation of narcotic use/requirements at baseline (initial encounter) and at 2 +/-1 months following initial assessment and therapy (ies) for treatment of spine-related pain symptoms and documentation of follow-up plan. Two rates can be reported for baseline and follow-up:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in status after Follow-up/Patient population with baseline", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAPM&R's Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "overall", "description": "Patient population with Follow-up/Patient population with baseline" }, { "name": "improvement", "description": "Patient population with improvement in status after Follow-up/Patient population with baseline" } ], "submissionMethods": [ "registry" ] }, { "measureId": "NPAGSC8", "title": "Complication Following Percutaneous Spine-Related Procedure", "description": "Proportion of patients undergoing percutaneous spine-related procedures who have a complication (specifically, CSF leak, deep venous thrombosis [DVT], pulmonary embolism [PE], myocardial infarction [MI], stroke, procedure related infection or unexpected new neurological deficit) in the 30-day post-procedure period.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "AAPM&R's Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPAGSC9", "title": "Unplanned Admission to Hospital Following Percutaneous Spine Procedure within the 30-Day Post-procedure Period", "description": "Percentage of patients aged 18 years and older who had any unplanned admission following percutaneous spine-related procedure within the 30-day post-procedure period", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "AAPM&R's Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR1", "title": "Notification to the ordering provider requesting myoglobin or CK-MB in the diagnosis of suspected acute myocardial infarction (AMI).", "description": "Percentage of ordering providers who have ordered a myoglobin or CK-MB for greater than 10% of the patients who have a suspected diagnosis of AMI, that were informed by the laboratory these tests are not beneficial for patients with a diagnosis of suspected AMI.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR10", "title": "Rate of amended pathology reports with a major discrepancy", "description": "Rate of amended pathology reports that have a major discrepancy.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR11", "title": "Rate of communicating results of an amended report with a major discrepancy to the responsible provider", "description": "Rate of communicating to the responsible provider the results of diagnostic reports that were amended due to a major discrepancy.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR12", "title": "Rate of cytopathology case review", "description": "Rate of retrospective review of all cytopathology cases.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR13", "title": "Rate of notification to clinical provider of a new diagnosis of malignancy", "description": "The rate of reporting to a responsible clinical provider from the pathologist when there is a new diagnosis of malignancy (other than squamous or basal cell sarcoma of the skin) from a pathology specimen", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR14", "title": "Frozen section diagnosis within 20 minutes of receipt in lab (single block frozen section)", "description": "The proportion of all single specimen, single block frozen section for which a diagnosis is reported within 20 minutes of receipt in the laboratory.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR2", "title": "Notification to the ordering provider requesting thyroid screening tests other than only a Thyroid Stimulating Hormone (TSH) test in the initial screening of a patient with a suspected thyroid disorder", "description": "Percentage of ordering providers who ordered thyroid screening tests other than only a TSH in greater than 10% of their patients for the evaluation of a patient with suspected non-neoplastic thyroid disease, who were informed by the laboratory these tests are not beneficial for the initial diagnosis of thyroid disease.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR3", "title": "Notification to the ordering provider requesting amylase testing in the diagnosis of suspected acute pancreatitis", "description": "Percentage of ordering providers who ordered an amylase test in greater than 10% of their patients for the evaluation of a patient with acute pancreatitis, who were informed by the laboratory this test is not beneficial for the diagnosis of pancreatitis.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR4", "title": "Time interval: critical value reporting for chemistry", "description": "Measurement of the time interval beginning with the time results are verified for any of the following Sodium (CPT – 84295), Potassium (CPT – 84132), Chloride (CPT – 82435), Calcium-total (CPT – 82310), Bicarbonate – CO2 (CPT – 80047, 80048, 80051, 80053, 80069), Ammonia (CPT – 82140), Total Bilirubin – Newborn (CPT – 82247), Arterial Blood Gases – pH, PO2, PCO2 (CPT – 82803, 82805, 82810), Glucose (CPT – 82947), Glucose – Newborn (CPT – 82947) tests until the critical value is reported by the laboratory. (Reporting done via phone, or secure electronic transmission, such as text messaging, messaging through Laboratory Information Systems, Electronic Health Records systems, or email with read receipt functionality). When notification is sent by email, performance met is contingent on read receipt received. If a read receipt is not received, this should be considered as performance not met.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR5", "title": "Time interval: critical value reporting for cerebrospinal fluid - white blood cell (CSF - WBC)", "description": "Measurement of the time interval beginning with the time results are verified (clinical) until the critical value is reported by the laboratory for CSF-WBC (CPT – 89050, 89051). (Done via phone, or secure electronic transmission, such as text messaging, messaging through Laboratory Information Systems, Electronic Health Records systems, or email with read receipt functionality). When notification is sent by email, performance met is contingent on read receipt received. If a read receipt is not received this should be considered as performance not met.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR6", "title": "Time interval: critical value reporting for toxicology", "description": "Measurement of the time interval beginning with the time results are verified until the critical value is reported by the laboratory for Carbamazepine (CPT – 80156, 80157), Phenobarbital (CPT – 80184), and Acetaminophen (CPT – 82003) toxicology tests. (Reporting done via phone, or secure electronic transmission, such as text messaging, messaging through Laboratory Information Systems, Electronic Health Records systems, or email with read receipt functionality). When notification is sent by email, performance met is contingent on read receipt received. If a read receipt is not received this should be considered as performance not met.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR7", "title": "Time interval: critical value reporting for troponin", "description": "Measurement of the time interval beginning with the time results are verified for Troponin (CPT - 84484) until the critical value is reported by the laboratory. (Reporting done via phone, email with read receipt functionality, or text). When notification is sent by email, performance met is contingent on read receipt received. If a read receipt is not received this should be considered as performance not met.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR8", "title": "Rate of review of slides with high-grade squamous intraepithelial lesion (HSIL) with negative cervical biopsies", "description": "Rate of review all available slides with high-grade squamous epithelial lesion (HSIL) Pap tests with subsequent cervical biopsies negative for dysplasia within 6 months.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR9", "title": "Rate of follow up letter after high-grade squamous intraepithelial lesion (HSIL) pap test", "description": "Rate of follow up notifications submitted to the responsible provider when a patient has the diagnosis of high-grade squamous epithelial lesion (HSIL) on a Pap test and has had no cervical biopsies within 6 months (+/- 2 weeks).", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OBERD22", "title": "Post Stroke Outcome and Follow-Up", "description": "This measure quantifies the quality of care of stroke patients by means of their change in score on a stroke-related patient reported outcome (PRO) instrument. The patient must have a diagnosis of index ischemic stroke (IS), intracerebral hemorrhage (ICH), or transient ischemic attack (TIA); must have completed the PRO instrument at discharge or within 7 days of the diagnosed event (the \"baseline\" measurement); and must have completed the same PRO between 90 and 120 days after the baseline (the \"follow-up\" measurement)", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Universal Research Solutions, LLC - OBERD QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OBERD23", "title": "Health Related Quality of Life: Patient Defined Outcomes", "description": "The finger dexterity goal of a guitarist is poorly measured by a standard question about difficulty buttoning a coat. The object of this measure is to track changes in the level of difficulty, which patients experience in performing a self-defined activity that is especially meaningful to their own quality of life intervention. The level of difficulty is rated on a 0-10 points scale for the self-defined activity and will be assessed based on comparison between pre-intervention and post-intervention scores.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Universal Research Solutions, LLC - OBERD QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OBERD25", "title": "Tracking Satisfaction Improvement with CG-CAHPS", "description": "This is an outcome measure: it measures actual improvement in patient satisfaction. It uses the same scoring approach, which underlies the statistics which CG-CAHPS reports annually. Each individual form is scored as the percentage of questions for which the EC received the top mark; the two most recent forms for each patient are compared; the percentage of patients whose scores did not go down is reported.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Universal Research Solutions, LLC - OBERD QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OBERD26", "title": "Cervical Spine Functional Outcomes", "description": "Percentage of patients 18 years of age and older who completed a baseline and, within the reporting period of Jan. 1, 2018 - Dec.31, 2018, a follow-up patient-reported cervical spine functional assessment (eg. NDI, or equivalent CAT assessment if available) to measure improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Universal Research Solutions, LLC - OBERD QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OBERD27", "title": "Foot/Ankle Functional Outcomes", "description": "Percentage of patients 18 years of age and older who completed a baseline and, within the reporting period of Jan. 1, 2018 - Dec.31, 2018, a follow-up patient-reported foot/ankle functional assessment (eg. FADI, AOFAS, FAAM, FAOS, FFI, Manchestor-Oxford Foot Pain and Disability Questionnaire, Manchestor-Oxford Foot Questionnaire or equivalent CAT assessment if available) to measure improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Universal Research Solutions, LLC - OBERD QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OBERD28", "title": "Hip Functional Outcomes", "description": "Percentage of patients 18 years of age and older who completed a baseline and, within the reporting period of Jan. 1, 2018 - Dec.31, 2018, a follow-up patient-reported hip functional assessment (eg Harris Hip Score, HOOS, HOOS-PS, HOOS Jr, Oxford Hip, or equivalent CAT assessment if available) to measure improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Universal Research Solutions, LLC - OBERD QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OBERD29", "title": "Knee Functional Outcomes", "description": "Percentage of patients 18 years of age and older who completed a baseline and, within the reporting period of Jan. 1, 2018 - Dec.31, 2018, a follow-up patient-reported knee functional assessment (eg. IKDC, KOOS, KOOS-PS, KOOS Jr. Oxford Knee, Kujala, or equivalent CAT assessment if available) to measure improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Universal Research Solutions, LLC - OBERD QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OBERD30", "title": "Lumbar Spine Functional Outcomes", "description": "Percentage of patients 18 years of age and older who completed a baseline and, within the reporting period of Jan. 1, 2018 - Dec.31, 2018, a follow-up patient-reported lumbar spine functional assessment (eg. ODI, or equivalent CAT assessment if available) to measure improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Universal Research Solutions, LLC - OBERD QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OBERD31", "title": "Quality of Life-Mental Health Outcomes", "description": "Percentage of patients 18 years of age and older who completed a baseline and, within the reporting period of Jan. 1, 2018 - Dec.31, 2018, follow-up quality of life (QoL) patient-reported outcomes assessment (VR-12, SF-12, SF-36, PROMIS Global 10 or equivalent Computer Adaptive Test (CAT) assessment if available) which yielded a mental component score to measure improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented. In addition, the AAOS Quality Outcomes Work Group recommends that QoL PROs in the clinical setting can lead to improved care.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Universal Research Solutions, LLC - OBERD QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OBERD32", "title": "Quality of Life - Physical Health Outcomes", "description": "Percentage of patients 18 years of age and older who completed a baseline and, within the reporting period of Jan. 1, 2018 - Dec.31, 2018, a follow-up quality of life (QoL) patient-reported outcomes assessment (VR-12, SF-12, SF-36, PROMIS Global 10 or equivalent Computer Adaptive Test (CAT) assessment if available) which yielded a physical component score to measure improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented. In addition, the AAOS Quality Outcomes Work Group recommends that QoL PROs in the clinical setting can lead to improved care.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Universal Research Solutions, LLC - OBERD QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OBERD33", "title": "Patient Acceptable Symptom State Outcomes", "description": "Percentage of patients 18 years or older who completed a baseline and, within the reporting period of Jan. 1, 2018 - Dec.31, 2018, a follow-up Patient Acceptable Symptoms State (PASS) assessment to measure improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Universal Research Solutions, LLC - OBERD QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OBERD34", "title": "Upper Extremity Functional Outcomes", "description": "Percentage of patients 18 years of age and older who completed a baseline and, within the reporting period of Jan. 1, 2018 - Dec.31, 2018, a follow-up patient-reported upper extremity functional assessment (eg. PROMIS Upper Extremity, ASES, ASES - elbow, Oxford Shoulder Score, Oxford Instability Score, Penn Shoulder Score, Boston questionnaire, DASH, QuickDASH, PRWE, or equivalent CAT assessment if available) to measure improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Universal Research Solutions, LLC - OBERD QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OEIS2", "title": "Emergent transfer from an outpatient, ambulatory surgical center, or office setting", "description": "Rate of emergent transfer from an outpatient, ASC, or office setting to an acute care facility as a result of an invasive peripheral vascular intervention.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Outpatient Endovascular and Interventional Society National Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OEIS3", "title": "Antiplatelet Therapy", "description": "Percentage of patients with PAD that have been prescribed an antiplatelet medication at the reported encounter.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Outpatient Endovascular and Interventional Society National Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OEIS4", "title": "Lipid-Lowering Medications for Patients with PAD", "description": "The rate at which patients with documented peripheral artery disease have documentation of a currently prescribed antihyperlipidemic medication treatment. This may include one of the following, Statin, Bile acid sequestrants, Niacin, Ezetimibe, Fibrates, PCSK9 Inhibitors.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Outpatient Endovascular and Interventional Society National Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OEIS6", "title": "Appropriate non-invasive arterial testing for patients with intermittent claudication who are undergoing a LE peripheral vascular intervention", "description": "Proportion of patients with non-invasive evaluations present/available prior to LE peripheral vascular interventions in patients with intermittent claudication.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Outpatient Endovascular and Interventional Society National Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ONSQIR18", "title": "Goal Setting and Attainment for Cancer Survivors", "description": "Percentage of patients aged 18 years and older who completed the final component of cancer treatment that have at least one post-treatment goal documented and progress of goal attainment documented within 12 months of completing the final component of cancer treatment.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "patientEngagementExperience", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Oncology QCDR Powered by Premier, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ONSQIR20", "title": "Fatigue Improvement", "description": "Percentage of patients aged 18 years and older with a diagnosis of cancer who reported moderate or greater level of fatigue at baseline who report mild or clinically insignificant fatigue during the 12-month measurement period.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Oncology QCDR Powered by Premier, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PIMSH1", "title": "Advance Care Planning in Stage 4 Disease", "description": "Percentage of patients with metastatic (stage 4) lung, colon, breast, pancreas or ovarian cancer who have a documented ACP discussion in the first 6 months after diagnosis.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Practice Insights by McKesson Specialty Health in Collaboration with The US Oncology Network", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PIMSH2", "title": "Utilization of GCSF in Metastatic Colon Cancer", "description": "Percentage of Stage 4 colon cancer patients receiving any white cell growth factors with chemotherapy", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Practice Insights by McKesson Specialty Health in Collaboration with The US Oncology Network", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PIMSH3", "title": "Combination chemotherapy is recommended or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1cN0M0 or Stage IB-III hormone receptor negative breast cancer", "description": "Percentage of female patients, age >18 at diagnosis, who have their first diagnosis of breast cancer (epithelial malignancy), at AJCC Stage T1cN0M0 (tumor greater than 1cm), or Stage 1B-III, whose primary tumor is progesterone and estrogen receptor negative recommended for multi-agent chemotherapy (recommended or administered) within 4 months (120 days) of diagnosis", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Practice Insights by McKesson Specialty Health in Collaboration with The US Oncology Network", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PINC1", "title": "Risk-adjusted 30 day Readmission for Acute Myocardial Infarction", "description": "Readmission to the same hospital for all causes within 30 days from the date of discharge of the index Acute Myocardial Infarction (AMI) admission", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Premier's Clinical Performance Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "PINC2", "title": "Risk-adjusted 30 day Readmission for Heart Failure", "description": "Readmission to the same hospital for all causes within 30 days from the date of discharge of the index Heart Failure (HF) admission", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Premier's Clinical Performance Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "PINC3", "title": "Risk-adjusted 30 day Readmission for Pneumonia", "description": "Readmission to the same hospital for all causes within 30 days from the date of discharge of the index Pneumonia (PN) admission", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Premier's Clinical Performance Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "PINC33", "title": "Risk-Adjusted Average Length of Inpatient Hospital Stay for Acute Myocardial Infarction", "description": "The average (geometric mean) hospital length of stay in days relative to the expected geometric mean length of stay of the Acute Myocardial Infarction (AMI) population of inpatients for the measurement year.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Premier's Clinical Performance Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "PINC34", "title": "Risk-Adjusted Average Length of Inpatient Hospital Stay for Heart Failure", "description": "The average (geometric mean) hospital length of stay in days relative to the expected geometric mean length of stay of the Heart Failure (HF) population of inpatients for the measurement year.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Premier's Clinical Performance Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "PINC35", "title": "Risk-Adjusted Average Length of Inpatient Hospital Stay for Pneumonia", "description": "The average (geometric mean) hospital length of stay in days relative to the expected geometric mean length of stay of the Pneumonia (PN) population of inpatients for the measurement year.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Premier's Clinical Performance Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "PINC4", "title": "Risk-adjusted 30 day Inpatient Mortality for Acute Myocardial Infarction", "description": "Mortality during hospital admission for patients with a Principal Diagnosis of Acute Myocardial Infarction (AMI).", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Premier's Clinical Performance Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "PINC5", "title": "Risk-adjusted 30 day Inpatient Mortality for Heart Failure", "description": "Mortality during hospital admission for patients with a Principal Diagnosis of Heart Failure (HF)", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Premier's Clinical Performance Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "PINC6", "title": "Risk-adjusted 30 day Inpatient Mortality for Pneumonia", "description": "Mortality during hospital admission for patients with a Principal Diagnosis of Pneumonia (PN)", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Premier's Clinical Performance Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "PP1", "title": "Annual Monitoring for Patients on Persistent Medications (MPM)", "description": "This measure assesses the percentage of patients 18 years of age and older who received a least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year. Report the following three rates and a total rate:\nRate 1: Annual Monitoring for patients on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB): At least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year.\nRate 2: Annual monitoring for patients on digoxin: At least one serum potassium, one serum creatinine and a serum digoxin therapeutic monitoring test in the measurement year.\nRate 3: Annual monitoring for patients on diuretics: At least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "PsychPRO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "weightedAverage", "strata": [ { "name": "ace", "description": "Annual Monitoring for patients on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB): At least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year." }, { "name": "digoxin", "description": "Annual monitoring for patients on digoxin: At least one serum potassium, one serum creatinine and a serum digoxin therapeutic monitoring test in the measurement year." }, { "name": "diuretics", "description": "Annual monitoring for patients on diuretics: At least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year." } ], "submissionMethods": [ "registry" ] }, { "measureId": "PP2", "title": "Follow-Up After Hospitalization for Schizophrenia (7- and 30-day)", "description": "The percentage of discharges for individuals 18 – 85 years of age who were hospitalized for treatment of schizophrenia and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported.\nRate 1: The percentage of individuals who received follow-up within 30 days of discharge\nRate 2: The percentage of individuals who received follow-up within 7 days of discharge", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "PsychPRO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "overall", "description": "The percentage of individuals who received follow-up within 30 days of discharge" }, { "name": "7days", "description": "The percentage of individuals who received follow-up within 7 days of discharge" } ], "submissionMethods": [ "registry" ] }, { "measureId": "PP3", "title": "ADHD: Symptom Reduction in Follow up Period", "description": "Percentage of children aged 4 through 18 years, with a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD), who demonstrated a 25% reduction in symptoms 6-12 months from baseline as measured using the Vanderbilt ADHD Diagnostic Rating Scale, regardless of treatment prescribed.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "PsychPRO", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PP4", "title": "Risky Behavior Assessment or Counseling by Age 18 Years", "description": "The percentage of adolescents with documentation of assessment or counseling for risky behavior by the age of 18 years. Four rates are reported: Rate 1: Risk Assessment or Counseling for Alcohol Use, Rate 2: Risk Assessment or Counseling for Tobacco Use, Rate 3: Risk Assessment or Counseling for Other Substance Use, and Rate 4: Risk Assessment or Counseling for Sexual Activity.", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "PsychPRO", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "weightedAverage", "strata": [ { "name": "counselalcohol", "description": "Risk Assessment or Counseling for Alcohol Use," }, { "name": "counseltobacco", "description": "Risk Assessment or Counseling for Tobacco Use," }, { "name": "counselsubstance", "description": "Risk Assessment or Counseling for Other Substance Use, and" }, { "name": "counselactivity", "description": "Risk Assessment or Counseling for Sexual Activity." } ], "submissionMethods": [ "registry" ] }, { "measureId": "PP5", "title": "Bipolar disorder: the percentage of patients diagnosed and treated for bipolar disorder who are monitored for change in their symptom complex within 12 weeks of initiating treatment; AND if there is no change or deterioration in symptoms, a revised care plan is documented following the 12 week monitoring phase", "description": "This measure is used to assess the percentage of patients diagnosed and treated for bipolar disorder who are monitored for change in their symptom complex within 12 weeks of initiating treatment AND who are provided with a documented revised care plan after the 12 week monitoring phase, if there is no change or deterioration in their symptoms.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "PsychPRO", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PP6", "title": "Pharmacological Treatment of Dementia", "description": "Percentage of patients with dementia or their caregivers with whom available guideline-appropriate pharmacological treatment options and nonpharmacological behavior and lifestyle modifications were discussed at least once in the last12-month period.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "PsychPRO", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PP7", "title": "Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC)", "description": "This measure is used to assess the percentage of children and adolescents 1 to 17 years of age who were on two or more concurrent antipsychotic medications.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "PsychPRO", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PPRNET13", "title": "Chronic Kidney Disease (CKD): eGFR Monitoring", "description": "The percentage of adult patients with Stage 3 or 4 CKD who have had a eGFR or serum creatinine in the past 6 months", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "PPRNet", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PPRNET14", "title": "Chronic Kidney Disease (CKD): Hemoglobin Monitoring", "description": "The percentage of adult patients with Stage 3B-Stage 5 CKD who have had a serum hemoglobin measured in the past 12 months", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "PPRNet", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PPRNET24", "title": "Appropriate Treatment for Adults with Upper Respiratory Infection", "description": "The percentage of adult patients seen within the past month and diagnosed with a common cold, pharyngitis or acute bronchitis who were not prescribed an antibiotic", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "PPRNet", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PPRNET28", "title": "NSAID or Cox 2 Inhibitor Use in Patients with Heart Failure (HF), Hypertension (HTN), or Chronic Kidney Disease (CKD)", "description": "The percentage of adult patients with HF, HTN or CKD who are not prescribed an NSAID or COX 2 inhibitor.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "PPRNet", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PPRNET29", "title": "Monitoring Serum Creatinine", "description": "The percentage of adult patients prescribed an ACEI, ARB, digoxin, diuretic or metformin who have had a serum creatinine measured in the past 12 months", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "PPRNet", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PPRNET31", "title": "Screening for Type 2 Diabetes", "description": "The percentage of patients 40 to 70 years of age who are overweight or obese and have been screened for type 2 diabetes in the past 3 years", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "PPRNet", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PPRNET32", "title": "Screening for albuminuria in patients at risk for CKD (DM and/or HTN)", "description": "Test for albuminuria or urine protein in adults with Diabetes Mellitus or Hypertension and without CKD", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "PPRNet", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PPRNET33", "title": "Avoiding Use of CNS Depressants in Patients on Long-Term Opioids", "description": "The percentage of patients on long-term opioid prescriptions without a concurrent prescription for an CNS depressant", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "PPRNet", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PPRNET34", "title": "Zoster (Shingles) Vaccination", "description": "The percentage of patients 50 years of age and older who have two Varicella Zoster (shingles) Shingrix vaccinations", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "PPRNet", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PPRNET8", "title": "Antiplatelet Medication for High Risk Patients", "description": "The percentage of high risk patients who are prescribed an antiplatelet medication. High risk patients include those patients ages 50-69 years with ≥ 10% 10-year CVD risk", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "PPRNet", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "QOPI11", "title": "Combination chemotherapy received within 4 months of diagnosis by women under 70 with AJCC stage IA (T1c) to III ER/PR negative breast cancer", "description": "Percentage of adult women under 70 with a diagnosis of AJCC stage IA (T1c) to III ER/PR negative breast cancer, who receive combination chemotherapy within 4 months of diagnosis", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "QOPI® Reporting Registry (QCDR) Brought to you by ASCO and ASTRO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "QOPI15", "title": "GCSF administered to patients who received chemotherapy for metastatic cancer (Lower Score -Better)", "description": "Percentage of adult patients with metastatic cancer who are administered chemotherapy and who receive a colony stimulating factor (Lower score - Better)", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "QOPI® Reporting Registry (QCDR) Brought to you by ASCO and ASTRO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "QOPI21", "title": "Oncology: Treatment Summary Communication – Radiation Oncology", "description": "Percentage of patients, regardless of age, with a diagnosis of cancer who have undergone brachytherapy or external beam radiation therapy who have a treatment summary report in the chart that was communicated to the physician(s) providing continuing care and to the patient within one month of completing treatment", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "QOPI® Reporting Registry (QCDR) Brought to you by ASCO and ASTRO", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "QOPI22", "title": "External Beam Radiotherapy for Bone Metastases", "description": "Percentage of patients, regardless of age, with a diagnosis of painful bone metastases and no history of previous radiation who receive external beam radiation therapy (EBRT) with an acceptable fractionation scheme as defined by the guideline.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "QOPI® Reporting Registry (QCDR) Brought to you by ASCO and ASTRO", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "QOPI5", "title": "Chemotherapy administered to patients with metastatic solid tumor with performance status of 3, 4, or undocumented (Lower Score - Better)", "description": "Percentage of patients with metastatic solid tumors and a performance status of 3, 4, or undocumented who receive chemotherapy", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "QOPI® Reporting Registry (QCDR) Brought to you by ASCO and ASTRO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "QUANTUM31", "title": "Central Line Ultrasound Guidance", "description": "Percentage of patients, regardless of age, in whom ultrasound guidance is used by the anesthesia clinician when placing a central line for those central lines that are placed in the internal jugular location.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MEDNAX QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "QUANTUM41", "title": "Case Cancellation on Day of Surgery", "description": "Surgical case cancellation occurring after care has been initiated by the anesthesia care team on the day of surgery. The cause of cancellation must relate to an issue related to the care of the anesthesiology clinician. Because the measure applies to the anesthesia care team, this measure can only be reported by groups who are reporting MIPS under the Group Reporting Option.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "MEDNAX QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RCOIR1", "title": "CKD 3-5 Patients Seen at the Recommended Frequency Levels", "description": "CKD 3-5 Patients Seen at Recommended Frequency Levels is the percentage of patients aged 18\nyears and older with a diagnosis for CKD 3-5 that have been seen by the nephrologist or\nnephrologist’s team member in the office setting within the lowest value of the suggested frequency\nrange per the Kidney Disease: Improving Global Outcomes (KDIGO).", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal and Vascular Outcome Improvement Program, powered by Forward Health Group", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RCOIR10", "title": "Upper Extremity Edema Improvement", "description": "Upper Extremity Edema Improvement is the percentage of patients with ESRD that present with upper\nextremity edema and report an improvement within 48 hours after an intervention has been performed.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal and Vascular Outcome Improvement Program, powered by Forward Health Group", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RCOIR11", "title": "Optimal End Stage Renal Disease (ESRD) Starts", "description": "Optimal End Stage Renal Disease (ESRD) Starts is the percentage of new adult ESRD patients\nduring the measurement period who experience a planned start of renal replacement therapy by receiving a preemptive kidney\ntransplant, by initiating home dialysis, or by initiating outpatient in-center hemodialysis via arteriovenous fistula or arteriovenous graft.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal and Vascular Outcome Improvement Program, powered by Forward Health Group", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RCOIR3", "title": "CKD 3-5 Patients with a Urine ACR or Urine PCR Lab Test", "description": "CKD 3-5 Patients with a Urine ACR or Urine PCR Lab Test is the percentage of patients aged 18\nyears and older with a diagnosis for CKD 3-5 and not receiving Renal Replacement Treatment that\nhave had a urine albumin to creatinine ratio lab test (ACR) or urine protein to creatinine ratio lab test\n(PCR) performed within the measurement period.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal and Vascular Outcome Improvement Program, powered by Forward Health Group", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RCOIR4", "title": "CKD 4-5 Patients with Transplant Referral", "description": "CKD 4-5 Patients with Transplant Referral is the percentage of patients aged 18 years and older with\na diagnosis for CKD 4-5 who are referred to a transplant center for kidney transplant evaluation\nwithin a 24 month period.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal and Vascular Outcome Improvement Program, powered by Forward Health Group", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RCOIR5", "title": "ESRD Prevalence of Home Dialysis or Self-Care", "description": "End Stage Renal Disease (ESRD) Prevalence of Home Dialysis or Self-Care is the percentage of all adult ESRD patients using a home modality, such as peritoneal dialysis or home hemodialysis, during the past 12 months.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal and Vascular Outcome Improvement Program, powered by Forward Health Group", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RCOIR7", "title": "Improved Access Site Bleeding", "description": "Improved Access Site Bleeding is the percentage of patients with ESRD and a vascular access site\nthat presented for prolonged bleeding, received an intervention, and subsequently reported a\nreduction in post-dialysis bleeding.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal and Vascular Outcome Improvement Program, powered by Forward Health Group", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RCOIR8", "title": "Post Procedure Bleeding", "description": "Post Procedure Bleeding is the percentage of patients with ESRD that had any peripheral vascular\nintervention performed and reported post procedural bleeding complications.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Renal and Vascular Outcome Improvement Program, powered by Forward Health Group", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RPAQIR1", "title": "Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy", "description": "Percentage of patients aged 18 years and older with a diagnosis of CKD (Stages 1-5, not receiving RRT) and proteinuria who were prescribed ACE inhibitor or ARB therapy within a 12-month period.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal Physicians Association QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RPAQIR11", "title": "Hospitalization Rate Following Procedures Performed under Procedure Sedation Analgesia", "description": "Percentage of inpatient hospitalizations immediately following procedures performed on patients 18 years and older under procedure sedation analgesia.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Renal Physicians Association QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RPAQIR12", "title": "Arterial Complication Rate Following Arteriovenous Access Intervention", "description": "Percentage of arterial complications in patients aged 18 years and older following angiography, angioplasty or thrombectomy procedures.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Renal Physicians Association QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RPAQIR13", "title": "Rate of Timely Documentation Transmission to Dialysis Unit/Referring Physician", "description": "Percentage of patients aged 18 years and older for whom documentation is sent to the dialysis unit or referring physician within two days of the procedure completion or consultation.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal Physicians Association QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RPAQIR14", "title": "Arteriovenous Graft Thrombectomy Success Rate", "description": "Percentage of clinically successful arteriovenous graft (AVG) thrombectomies for patients aged 18 years and older.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal Physicians Association QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RPAQIR15", "title": "Arteriovenous Fistulae Thrombectomy Success Rate", "description": "Percentage of clinically successful arteriovenous fistulae (AVF) thrombectomies for patients aged 18 years and older.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal Physicians Association QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RPAQIR16", "title": "Peritoneal Dialysis Catheter Success Rate", "description": "Percentage of clinically successful peritoneal dialysis (PD) catheter placements in patients aged 18 and older.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal Physicians Association QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RPAQIR17", "title": "Peritoneal Dialysis Catheter Exit Site Infection Rate", "description": "Percentage of patients aged 18 years and older with an exit site infection within 2 weeks of a peritoneal dialysis (PD) catheter invasive intervention.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Renal Physicians Association QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RPAQIR18", "title": "Advance Directives Completed", "description": "Percentage of patients aged 18 years and older with a diagnosis of Stage 3, 4 & 5 chronic kidney disease (CKD) or ESRD who have advance directives or end of life medical orders completed based on their preferences.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal Physicians Association QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RPAQIR2", "title": "Adequacy of Volume Management", "description": "Percentage of calendar months within a 12-month period during which patients aged 18 years and older with a diagnosis of end-stage renal disease (ESRD) undergoing maintenance hemodialysis in an outpatient dialysis facility have an assessment of the adequacy of volume management from a nephrologist.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal Physicians Association QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RPAQIR4", "title": "Arteriovenous Fistula Rate", "description": "Percentage of calendar months within a 12-month period during which patients aged 18 years and older with a diagnosis of end-stage renal disease (ESRD) and receiving maintenance hemodialysis are using an autogenous arteriovenous (AV) fistula with two needles in an outpatient dialysis facility.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal Physicians Association QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RPAQIR5", "title": "Transplant Referral", "description": "Percentage of patients aged 18 years and older with a diagnosis of end-stage renal disease (ESRD) on hemodialysis or peritoneal dialysis for 90 days or longer who are referred to a transplant center for kidney transplant evaluation within a 12-month period.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal Physicians Association QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RPAQIR9", "title": "Advance Care Planning (Pediatric Kidney Disease)", "description": "Percentage of patients aged 17 years and younger with a diagnosis of ESRD on hemodialysis or peritoneal dialysis for whom there is documentation of a discussion regarding advance care planning.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal Physicians Association QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, 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"nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SCG1", "title": "SCG1 Evaluation of High Risk Pain Medications for MME", "description": "Percentage of patients aged 18 years and older prescribed and actively taking one or more high risk pain medications and evaluated for clinical appropriateness of morphine milligram equivalents (MME)", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "SCG Health", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SCG2", "title": "SCG2 Outcome Assessment for Patients Prescribed Ankle Orthosis for Ambulation and Functional Improvement", "description": "Percentage of patients 18 years and older who had at least two medical visits during the performance period, and for whom an ankle orthosis was prescribed to assist with ambulation AND report a significant improvement in ambulation and function with the orthosis using a standardized tool within the performance period", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "SCG Health", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SCG3", "title": "Outcome Assessment for Patients Prescribed Foot Orthosis for Ambulation and Functional Improvement", "description": "Percentage of patients 18 years and older with a deformity of the foot or forefoot, who had at least two medical visits during the performance period, and for whom a foot orthosis was prescribed to assist with ambulation AND report a significant improvement in ambulation and function with the orthosis using a standardized tool within the reporting period", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "SCG Health", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SCG4", "title": "Prevention of Antibiotic or Herbal Supplement Impairment of Anesthesia", "description": "Percentage of patients, regardless of age, who are prescribed antibiotics or taking natural herbal supplements and undergoing a surgical, therapeutic or diagnostic procedures under anesthesia during the performance period and who have a documented use of a pre-operative assessment for anesthesia impairment AND there was no impairment of the effectiveness of anesthesia", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "SCG Health", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": 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"metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SDPAD1", "title": "Education of patients with inflammatory diseases regarding increased cardiovascular risk and the need for PCP evaluation", "description": "Percentage of patients, regardless of age, with a current diagnosis of psoriasis or hidradenitis suppurativa who were seen for an office visit during the one-year measurement period and who have a documented discussion regarding increased risk for cardiovascular comorbidities including a referral to the PCP for that screening and document that the patient followed through on the referral", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Dermatology PA QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SDPAD2", "title": "HCV testing in Lichen Planus", "description": "Percentage of patients, regardless of age, with a current diagnosis of lichen planus who were seen for an office visit during the one year measurement period and for whom a HCV antibody and liver function tests have been performed or documented", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Dermatology PA QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SDPAD3", "title": "Avoiding antibiotic use in rupture epidermal inclusion cyst", "description": "Percentage of patients with a diagnosis of inflamed epidermal cyst and no signs of infection and who were not prescribed antibiotics", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Dermatology PA QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SDPAD4", "title": "Appropriate Testing and Treatment of Nail tinea infection", "description": "Percentage of patients, regardless of age, with a current diagnosis of tinea unguium who were seen for an office visit during the one-year measurement period, for whom appropriate testing for tinea was accomplished prior to systemic fungal treatment", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Dermatology PA QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMD23", "title": "Urgent Result: Breast Specimen Radiography", "description": "Efficiency of reporting radiographic findings of Breast Specimen Radiography", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD, LLC in collaboration with SunCoast RHIO", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMD24", "title": "Critical Result: Testicular Torsion", "description": "Efficiency of reporting radiographic findings of Testicular Torsion", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD, LLC in collaboration with SunCoast RHIO", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMD25", "title": "Critical Result: Subdural hematoma", "description": "Efficiency of reporting radiographic findings of Subdural hematoma", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD, LLC in collaboration with SunCoast RHIO", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMD26", "title": "GI Radiography Result Notification\n•Critical Result: Bowel Obstruction\n•Critical Result: Sigmoid Volvulus", "description": "•Efficiency of reporting radiographic findings of Bowel Obstruction\n•Efficiency of reporting radiographic findings of Sigmoid Volvulus", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD, LLC in collaboration with SunCoast RHIO", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMD27", "title": "Chest Imaging Result Notification:\n•Critical Result: Pneumothorax\n•Critical Result: Tension Pneumothorax\n•Follow Up Result: Suspicious Lung Nodule", "description": "•Efficiency of reporting radiographic findings of Pneumothorax\n•Efficiency of reporting radiographic findings of Tension Pneumothorax\n•Efficiency of reporting radiographic findings of Suspicious Lung Nodule", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD, LLC in collaboration with SunCoast RHIO", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMD28", "title": "Musculoskeletal Radiology Result Notification:\n•Critical Result: Fracture C-Spine\n•Urgent Result: Osteomyelitis\n•Urgent Result: Meniscal Tear", "description": "•Efficiency of reporting radiographic findings of C-Spine fracture\n•Efficiency of reporting radiographic findings of Osteomyelitis\n•Efficiency of reporting radiographic findings of Meniscal Tear", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD, LLC in collaboration with SunCoast RHIO", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMX1", "title": "Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia", "description": "Percentage of patients 25 - 75 years of age with schizophrenia and cardiovascular disease, who had an LDL-C test during the performance period.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Spectra-Medix eMeasures360™ QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMX2", "title": "Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications", "description": "Percentage of patients 18 - 64 years of age with schizophrenia or bipolar disorder, who were dispensed an antipsychotic medication and had a diabetes screening test during the performance period.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Spectra-Medix eMeasures360™ QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMX3", "title": "SMX1004: Use of Multiple Concurrent Antipsychotics in Children and Adolescents", "description": "Percentage of children and adolescents 1-17 years of age who were on two or more concurrent antipsychotic medications.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Spectra-Medix eMeasures360™ QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMX5", "title": "Medication Adherence for Diabetes Medication", "description": "Percent of patients with a prescription for a diabetes medication who fill their prescriptions often enough to cover 80% or more of the time they are supposed to be taking the medication", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Spectra-Medix eMeasures360™ QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMX6", "title": "Screening for Psychiatric or Behavioral Health Disorders", "description": "Percent of all encounters for patients with a diagnosis of epilepsy where the patient was screened for psychiatric or behavioral disorders", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Spectra-Medix eMeasures360™ QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMX7", "title": "Medication Adherence for Hypertension", "description": "Percent of patients with a prescription for a blood pressure medication who fill their prescriptions often enough to cover 80% or more of the time they are supposed to be taking the medication", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Spectra-Medix eMeasures360™ QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMX8", "title": "Assessment and Intervention for Psychosocial Distress in Adults Receiving Cancer Treatment", "description": "Percentage of patients 18 years of age and older with a diagnosis of cancer who are assessed for psychosocial distress, and if moderately to severely distressed, have a documented intervention during the performance period", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Spectra-Medix eMeasures360™ QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMX9", "title": "Mental Health Assessment for Patients with orthopedic conditions", "description": "Percentage of patients 18 years of age and older with musculoskeletal disease who completed baseline and follow-up patient-reported Mental Health assessments", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Spectra-Medix eMeasures360™ QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SPINEIQ3", "title": "Repeated X-ray Imaging", "description": "Percent of patients with spine-related disorders who received two or more of the same x-ray imaging studies for the purpose of monitoring the patient’s condition, either performed or ordered by an eligible clinician within the measurement period.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "The Spine Institute for Quality Conservative Care: QCDR For Individuals - Powered by Premier, Inc", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SPINEIQ5", "title": "Change in Functional Outcomes", "description": "Percentage of patients who report a 30% or greater decrease in PROMIS Pain Interference Score from the initial assessment to final assessment during an episode of care for a spine-related disorder.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "The Spine Institute for Quality Conservative Care: QCDR For Individuals - Powered by Premier, Inc", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SPINEIQ6", "title": "Change in Pain Intensity", "description": "Percentage of patients who report a 30% or greater decrease in PROMIS Pain Intensity Score from the initial assessment to final assessment during an episode of care for a spine-related disorder.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "The Spine Institute for Quality Conservative Care: QCDR For Individuals - Powered by Premier, Inc", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SPINEIQ7", "title": "MRI of the lumbar spine without prior conservative care", "description": "Percentage of patients with diagnosis of low back pain receiving MRI in the absence of prior conservative care", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "The Spine Institute for Quality Conservative Care: QCDR For Individuals - Powered by Premier, Inc", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SPINETRACK1", "title": "Percent of patients meeting MCID thresholds for back or neck pain", "description": "Calculation of the percent of patients who meet the minimum clinically important difference (MCID) threshold for improvement in back or neck pain following a spine surgical intervention (cervical or lumbar)", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SpineTRACK Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SPINETRACK2", "title": "Percent of patients meeting MCID thresholds for leg or arm pain", "description": "Calculation of the percent of patients who meet the minimum clinically important difference (MCID) threshold for improvement in leg or arm pain following a spine surgical intervention (cervical or lumbar)", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SpineTRACK Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SPINETRACK3", "title": "Percent of patients meeting MCID thresholds for pain-related disability (ODI/NDI)", "description": "Calculation of the percent of patients who meet the minimum clinically important difference (MCID) threshold for improvement in pain-related disability following a spine surgical intervention (cervical or lumbar)", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SpineTRACK Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SPINETRACK4", "title": "Percent of patients meeting SCB thresholds for back or neck pain", "description": "Calculation of the percent of patients who meet the substantial clinical benefit (SCB) thresholds for improvement in back or neck pain following a spine surgical intervention (cervical or lumbar)", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SpineTRACK Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SPINETRACK5", "title": "Percent of patients meeting SCB thresholds for leg or arm pain", "description": "Calculation of the percent of patients who meet the substantial clinical benefit (SCB) thresholds for improvement in leg or arm pain following a spine surgical intervention (cervical or lumbar)", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SpineTRACK Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SPINETRACK6", "title": "Percent of patients meeting SCB thresholds for pain-related disability (ODI/NDI)", "description": "Calculation of the percent of patients who meet the substantial clinical benefit (SCB) thresholds for improvement in pain-related disability following a spine surgical intervention (cervical or lumbar)", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SpineTRACK Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SQOD1", "title": "Assessment and Management of Muscle Spasticity--Inpatient", "description": "Percentage of patients, regardless of age with a diagnosis of stroke, acquired brain injury (ABI), spinal cord injury (SCI), cerebral palsy (CP), or multiple sclerosis (MS) who are admitted to inpatient rehabilitation, skilled nursing facility, or long-term care hospital with a documented assessment of muscle spasticity AND if muscle spasticity is present, a plan of care to monitor and/or manage muscle spasticity is documented prior to discharge\n\nThree rates are reported:\nRate 1: Percentage of patients, regardless of age with a diagnosis of stroke, acquired brain injury (ABI), spinal cord injury (SCI), cerebral palsy (CP), or multiple sclerosis (MS) who are admitted to inpatient rehabilitation, skilled nursing facility, or long-term care hospital with a documented assessment of muscle spasticity prior to discharge\n\nRate 2: Percentage of patients regardless of age with a diagnosis of stroke, acquired brain injury (ABI), spinal cord injury (SCI), cerebral palsy (CP), or multiple sclerosis (MS) who are admitted to inpatient rehabilitation, skilled nursing facility, or long-term care hospital with muscle spasticity who have a documented plan of care to monitor and/or manage muscle spasticity prior to discharge.\n\nRate 3: Percentage of patients, regardless of age with a diagnosis of stroke, acquired brain injury (ABI), spinal cord injury (SCI), cerebral palsy (CP), or multiple sclerosis (MS) who are admitted to inpatient rehabilitation, skilled nursing facility, or long-term care hospital with a documented assessment of muscle spasticity AND if muscle spasticity is present, a plan of care to monitor and/or manage muscle spasticity is documented prior to discharge", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAPM&R's Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "assessment", "description": "Percentage of patients, regardless of age with a diagnosis of stroke, acquired brain injury (ABI), spinal cord injury (SCI), cerebral palsy (CP), or multiple sclerosis (MS) who are admitted to inpatient rehabilitation, skilled nursing facility, or long-term care hospital with a documented assessment of muscle spasticity prior to discharge" }, { "name": "planofcare", "description": "Percentage of patients regardless of age with a diagnosis of stroke, acquired brain injury (ABI), spinal cord injury (SCI), cerebral palsy (CP), or multiple sclerosis (MS) who are admitted to inpatient rehabilitation, skilled nursing facility, or long-term care hospital with muscle spasticity who have a documented plan of care to monitor and/or manage muscle spasticity prior to discharge." }, { "name": "overall", "description": "Percentage of patients, regardless of age with a diagnosis of stroke, acquired brain injury (ABI), spinal cord injury (SCI), cerebral palsy (CP), or multiple sclerosis (MS) who are admitted to inpatient rehabilitation, skilled nursing facility, or long-term care hospital with a documented assessment of muscle spasticity AND if muscle spasticity is present, a plan of care to monitor and/or manage muscle spasticity is documented prior to discharge" } ], "submissionMethods": [ "registry" ] }, { "measureId": "SQOD2", "title": "Management of Muscle Spasticity--Outpatient", "description": "Percentage of patients, regardless of age with a diagnosis of stroke, acquired brain injury (ABI), spinal cord injury (SCI), cerebral palsy (CP), or multiple sclerosis (MS) with muscle spasticity, who are seen for an office visit during the measurement period with a documented plan of care to monitor and/or manage muscle spasticity", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAPM&R's Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SQOD3", "title": "Post-Acute Brain Injury: Depression Screening and Follow-Up Plan of Care", "description": "Percentage of patients aged 18 years and older who have experienced an acute brain injury, seen for an office visit during the measurement period who were screened for depression using a validated tool and if screened positive AND if positive, a follow up plan of care is documented on the date of the positive screen", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAPM&R's Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SQOD4", "title": "Family Training—Inpatient Rehabilitation/Skilled Nursing Facility-Discharged to Home", "description": "Percentage of patients aged 18 years and older who have experienced a stroke, discharged from inpatient rehabilitation, skilled nursing facility, or long-term care hospital to home, whose family/caregiver(s) demonstrated successful teach-back regarding skills for care of the patient in the home setting", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAPM&R's Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SQOD5", "title": "Functional Assessment to Determine Rehabilitation Needs", "description": "Percentage of patients aged 18 and older who have experienced a stroke and are admitted to acute care who have a comprehensive functional assessment to determine rehabilitation needs performed prior to discharge.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAPM&R's Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "STS1", "title": "Prolonged Length of Stay Following Coronary Artery Bypass Grafting", "description": "Percentage of patients aged 18 years and older undergoing isolated CABG with an inpatient postoperative length of stay of more than 14 days whether patient is alive or dead at discharge", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "STS National Database", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "STS10", "title": "Operative Mortality for Lobectomy", "description": "Percentage of patients who underwent lobectomy surgery for lung cancer who suffer an operative mortality.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "STS National Database", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "STS11", "title": "Lobectomy – Air Leak Greater than 5 Days", "description": "Percentage of patients who underwent lobectomy surgery for lung cancer who have a post-operative air leak greater than 5 days.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "STS National Database", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "STS12", "title": "Lobectomy – Unplanned Return to OR", "description": "Percentage of patients who underwent lobectomy surgery for lung cancer who require a return to the operating room (OR) during the current hospitalization for any reason.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "STS National Database", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "STS13", "title": "Recording Performance Status Prior to Lung Cancer Resection", "description": "Percentage of surgical patients undergoing resection for lung cancer who had their performance status recorded within two weeks prior to the surgery date", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "STS National Database", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "STS3", "title": "Prolonged Length of Stay for Coronary Artery Bypass Grafting (CABG) + Valve Replacement", "description": "Percentage of patients aged 18 years and older undergoing CABG + valve replacement with an inpatient postoperative length of stay of more than 14 days whether patient is alive or dead at discharge", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "STS National Database", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "STS5", "title": "Prolonged Length of Stay following Valve Surgery", "description": "Percentage of patients aged 18 years and older undergoing isolated valve surgery with an inpatient postoperative length of stay of more than 14 days whether patient is alive or dead at discharge", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "STS National Database", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "STS7", "title": "Patient Centered Surgical Risk Assessment and Communication for Cardiac Surgery", "description": "Percentage of patients age 18 and older undergoing a non-emergency risk modeled cardiac surgery procedure that had personalized risk assessment using the STS risk calculator and discussed those risks with the surgeon.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "patientEngagementExperience", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "STS National Database", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "STS8", "title": "Operative Mortality for Esophageal Resection", "description": "Percentage of patients who underwent esophageal resection surgery for esophageal cancer who suffer an operative mortality.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "STS National Database", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "STS9", "title": "Recording Performance Status prior to Esophageal Cancer Resection", "description": "Percentage of surgical patients undergoing resection for esophageal cancer who had their performance status recorded within two weeks prior to the surgery date", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "STS National Database", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "UREQA1", "title": "UR002 - Ankylosing Spondylitis: Controlled Disease", "description": "Percentage of qualifying visits for patients aged 18 years and older with a diagnosis of ankylosing spondylitis whose most recent BASDAI score is less than 4.\n\nThis measure is reported for each qualifying visit", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "intermediateOutcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "UREQA (United Rheumatology Effectiveness and Quality Analytics)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "UREQA2", "title": "UR003 - Ankylosing Spondylitis: Appropriate Pharmacologic Therapy", "description": "Percentage of patients aged 18 years and older with a first diagnosis of ankylosing spondylitis who are treated with nonsteroidal anti-inflammatory drugs (NSAIDs) before initiation of biologic therapy.\n\nThis measure is reported once per reporting period", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "UREQA (United Rheumatology Effectiveness and Quality Analytics)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "UREQA3", "title": "UR008 - Controlled Gout for Patients on Urate-Lowering Pharmacologic Therapy", "description": "Percentage of patients aged 18 years and older with a diagnosis of gout treated with urate-lowering pharmacologic therapy for at least 6 months whose most recent serum urate result is less than 6.0 mg/dL.\n\nThis measure is reported once per reporting period", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "intermediateOutcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "UREQA (United Rheumatology Effectiveness and Quality Analytics)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "UREQA4", "title": "UR007 - Folic or Folinic Acid Therapy for Patients Treated with Methotrexate", "description": "Percentage of patients aged 18 years and older being treated with methotrexate who are concomitantly treated with folic or folinic acid.\n\nThis measure is reported once per reporting period", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "UREQA (United Rheumatology Effectiveness and Quality Analytics)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "UREQA5", "title": "UR006 - Regular Evaluation of Psoriatic Arthritis (PsA)", "description": "Percentage of patients aged 18 and older with a diagnosis of psoriatic arthritis (PsA) who have had a qualifying office visit at least every 90 days throughout the performance period.\n\nThis measure is reported once per reporting period", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "UREQA (United Rheumatology Effectiveness and Quality Analytics)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "USWR13", "title": "Patient Vital Sign Assessment and Blood Glucose Check Prior to HBOT Treatment", "description": "Percentage of HBOT treatments of patients aged 18 years and older who have their vital signs and blood glucose level assessed prior to undergoing hyperbaric oxygen therapy (HBOT). Three rates are reported for this measure.\n\nRate 1:\tPercentage of patients undergoing a hyperbaric treatment (HBOT) whose vital signs are taken.\nRate 2: Percentage of diabetic patients undergoing a hyperbaric treatment (HBOT) who had a blood glucose check.\nRate 3: Percentage of patients undergoing HBOT with vital signs taken and those with diabetes had a blood glucose check.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "vital", "description": "Percentage of patients undergoing a hyperbaric treatment (HBOT) whose vital signs are taken." }, { "name": "glucose", "description": "Percentage of diabetic patients undergoing a hyperbaric treatment (HBOT) who had a blood glucose check." }, { "name": "overall", "description": "Percentage of patients undergoing HBOT with vital signs taken and those with diabetes had a blood glucose check." } ], "submissionMethods": [ "registry" ] }, { "measureId": "USWR16", "title": "Major Amputation in Wagner 3, 4, or 5 Diabetic Foot Ulcers (DFUs) Treated with HBOT", "description": "Percentage of ulcers of patients aged 18 years or older with a diagnosis of a Wagner Grade 3, 4, or 5 diabetic foot ulcer (DFU) whose ulcer has an outcome of major amputation 6 months after completion of a course of HBOT, stratified by the Wound Healing Index.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "USWR20", "title": "Nutritional Screening and Intervention Plan in Patients with Chronic Wounds and Ulcers", "description": "The percentage of patients aged 18 years and older with a diagnosis of a wound or ulcer of any type who undergo nutritional screening with a validated tool (such as the Nestlé MNA) within the 12-month reporting period, and for whom an appropriate nutritional intervention was ordered based on the results of the tool.\n\nUsing the MNA Short Form algorithm, if a patient at risk of malnutrition has an MNA score of 8-11 and documented weight loss, the clinician would be provided with general treatment, monitoring or rescreening recommendations. These include: nutrition interventions (e.g. diet enhancement and oral supplementation of 400 kcal/d2), close weight monitoring, and a more in depth nutrition assessment. Malnourished patients with scores of 0-7 would be offered treatment with nutritional intervention (ONS 400-600 kcal/d2 and diet enhancement), close weight monitoring and a more in depth nutrition assessment. No specific products will be recommended as part of the measure.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "USWR22", "title": "Patient Reported Nutritional Assessment in Patients with Wounds and Ulcers", "description": "The percentage of patients aged 18 years and older with a diagnosis of a wound or ulcer of any type who self-report nutritional screening with a validated tool (such as the Self-MNA by Nestlé) within the 12-month reporting period.\n\nUsing the Self-MNA® by Nestlé, if a patient at risk of malnutrition has an MNA score of 8-11 and documented weight loss, the clinician should subsequently create a follow up plan (e.g. diet enhancement and oral supplementation of 400 kcal/d2), close weight monitoring, and a more in depth nutrition assessment. Malnourished patients with scores of 0-7 would be offered treatment with nutritional intervention (ONS 400-600 kcal/d2 and diet enhancement), close weight monitoring and a more in depth nutrition assessment. No specific products will be recommended as part of the measure. Implementation of an intervention plan based on nutritional screening is CDR measure 20.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "USWR23", "title": "Non Invasive Arterial Assessment of patients with lower extremity wounds or ulcers for determination of healing potential", "description": "Percentage of patients aged 18 years or older with a non healing lower extremity wounds or ulcers that underwent a non-invasive arterial assessment once in a 12 month period, stratified by ABI, perfusion pressure, or oximetry.\n\nThere are four rates reported for this measure. The four rates will be risk stratified into three buckets which are the following:\nRate 1:\tNo evidence of arterial disease and ischemia is not a contributor to non-healing\nRate 2:\tPossible arterial compromise (possible reduced flow), but the patient may still be able to heal the wound(s) or ulcer(s)\nRate 3:\tEvidence of arterial disease- patient should be referred to specialist for vascular assessment if not currently in the care of a vascular expert. Ischemia may be the reason the patient has failed to heal.\nRate 4:\tThe average of the three risk stratified buckets which will be the performance rate in the XML submitted.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "noevidence", "description": "No evidence of arterial disease and ischemia is not a contributor to non-healing" }, { "name": "possiblecompromise", "description": "Possible arterial compromise (possible reduced flow), but the patient may still be able to heal the wound(s) or ulcer(s)" }, { "name": "evidence", "description": "Evidence of arterial disease- patient should be referred to specialist for vascular assessment if not currently in the care of a vascular expert. Ischemia may be the reason the patient has failed to heal." }, { "name": "overall", "description": "The average of the three risk stratified buckets which will be the performance rate in the XML submitted." } ], "submissionMethods": [ "registry" ] }, { "measureId": "USWR24", "title": "Patient Reported Experience of Care: Wound Outcome", "description": "All eligible patients with wounds or ulcers who completed of Wound Outcome Questionnaire who showed 10% improvement at discharge or transfer to another site of care during the 12 month reporting period.", "nationalQualityStrategyDomain": "Person and Care-giver-Centered Experiences and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "VCMAHEMR1", "title": "Advance Care planning: Electronic submission of new POLST/MOLST/POST/MOST (\"orders for life-sustaining treatment\" or \"orders for scope of treatment\") into an eRegistry powered by Medcordance", "description": "For patients with terminal conditions, physicians shall provide advance care planning to identify a patient's end-of-life treatment preferences and electronically submit a new physician's order for life sustaining treatment (\"POLST\"; also known as \"MOST\", \"MOLST\", or \"POST\" in some states) which is submitted into a POLST eRegistry Platform powered by Medcordance, unless declined by patient.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Ventura County Medical Association Medcordance and POLST Collaboration", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "WCHQ10", "title": "Diabetes Care All or None Outcome Measure: Optimal Control", "description": "The percentage of diabetes patients 18 through 75 years of age who had the following during the 12-month measurement period:\n All or None Outcome Measure (Optimal Control) composite of A1C <8.0%, BP <130/80, Tobacco Non-User, Statin Use, and Daily Aspirin or Other Antiplatelet for diabetes patients with IVD.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Physician Compass", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "WCHQ15", "title": "Screening For Osteoporosis", "description": "The percentage of women age 65 through 85 who had a minimum of one bone densitometry test at age 60 or above or have a diagnosis of osteoporosis or osteopenia.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Physician Compass", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "WCHQ32", "title": "Controlling High Blood Pressure: eGFR Test Annually", "description": "The percentage of essential hypertension patients 18 through 85 years of age who had the following during the 12 month measurement period:\n\nAn eGFR (Estimated Glomerular Filtration Rate) test annually", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Physician Compass", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "WCHQ9", "title": "Diabetes Care All or None Process Measure: Optimal Testing", "description": "The percentage of diabetes patients 18 through 75 years of age who had the following during the 12-month measurement period:\n All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidney Function\nMonitoring Test and one eGFR Test", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Physician Compass", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "isToppedOutByProgram": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] } ]