[
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PCMH",
    "cehrtEligible": false,
    "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.",
    "title": "Patient Centered Medical Home Attestation",
    "weight": null,
    "subcategoryId": null
  },
  {
    "measureId": "ACI_INFBLO_1",
    "category": "aci",
    "title": "Prevention of Information Blocking Attestation",
    "description": "I have not  knowingly and willfully take action to limit or restrict the interoperability of certified EHR technology.\nI have responded to requests to retrieve or exchange information—including requests from patients and other health care providers regardless of the requestor's affiliation or technology.\nI have implemented appropriate standards and processes to ensure that its certified EHR technology was connected in accordance with applicable law and standards, allowed patients timely access to their electronic health information; and supported exchange of electronic health information with other health care providers.",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": 0,
    "isRequired": true,
    "isBonus": false,
    "measureSets": [],
    "objective": null,
    "reportingCategory": "preAttestation",
    "substitutes": []
  },
  {
    "measureId": "ACI_ONCDIR_1",
    "category": "aci",
    "title": "ONC Direct Review Attestation",
    "description": "I have (1) acknowledged the requirement to cooperate in good faith with ONC direct review health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received;\nAND (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": "preAttestation",
    "substitutes": []
  },
  {
    "measureId": "ACI_ONCACB_1",
    "category": "aci",
    "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": "preAttestation",
    "substitutes": []
  },
  {
    "measureId": "ACI_IACEHRT_1",
    "category": "aci",
    "title": "CEHRT Used",
    "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": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "ACI_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": [
      "ACI_EP_1",
      "ACI_TRANS_EP_1",
      "ACI_TRANS_LVPP_1"
    ]
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "ACI_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": [
      "ACI_TRANS_EP_1",
      "ACI_LVPP_1",
      "ACI_EP_1"
    ]
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "ACI_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": [
      "ACI_HIE_1",
      "ACI_TRANS_HIE_1",
      "ACI_TRANS_LVOTC_1"
    ]
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "ACI_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": [
      "ACI_TRANS_HIE_1",
      "ACI_HIE_1",
      "ACI_LVOTC_1",
      "ACI_HIE_2",
      "ACI_LVITC_1"
    ]
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "ACI_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": [
      "ACI_HIE_2",
      "ACI_TRANS_HIE_1",
      "ACI_TRANS_LVOTC_1"
    ]
  },
  {
    "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,
    "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,
    "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": "0005",
    "isInverse": false,
    "strata": [],
    "isHighPriority": true,
    "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: Access to Specialists",
    "description": "",
    "nationalQualityStrategyDomain": null,
    "measureType": "patientEngagementExperience",
    "measureId": "CAHPS_4",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [],
    "isHighPriority": true,
    "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: Health Promotion and Education",
    "description": "",
    "nationalQualityStrategyDomain": null,
    "measureType": "patientEngagementExperience",
    "measureId": "CAHPS_5",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [],
    "isHighPriority": true,
    "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: Shared Decision-Making",
    "description": "",
    "nationalQualityStrategyDomain": null,
    "measureType": "patientEngagementExperience",
    "measureId": "CAHPS_6",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [],
    "isHighPriority": true,
    "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: Health Status and Functional Status",
    "description": "",
    "nationalQualityStrategyDomain": null,
    "measureType": "patientEngagementExperience",
    "measureId": "CAHPS_7",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [],
    "isHighPriority": true,
    "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: Care Coordination",
    "description": "",
    "nationalQualityStrategyDomain": null,
    "measureType": "patientEngagementExperience",
    "measureId": "CAHPS_8",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [],
    "isHighPriority": true,
    "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: Courteous and Helpful Office Staff",
    "description": "",
    "nationalQualityStrategyDomain": null,
    "measureType": "patientEngagementExperience",
    "measureId": "CAHPS_9",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0005",
    "isInverse": false,
    "strata": [],
    "isHighPriority": true,
    "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: Helping You Take Medications as Directed",
    "description": "",
    "nationalQualityStrategyDomain": null,
    "measureType": "patientEngagementExperience",
    "measureId": "CAHPS_10",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [],
    "isHighPriority": true,
    "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: Stewardship of Patient Resources",
    "description": "",
    "nationalQualityStrategyDomain": null,
    "measureType": "patientEngagementExperience",
    "measureId": "CAHPS_11",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [],
    "isHighPriority": true,
    "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: Between Visit Communication",
    "description": "",
    "nationalQualityStrategyDomain": null,
    "measureType": "patientEngagementExperience",
    "measureId": "CAHPS_12",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [],
    "isHighPriority": true,
    "primarySteward": "Agency for Healthcare Research & Quality",
    "submissionMethods": [
      "certifiedSurveyVendor"
    ],
    "measureSets": [
      "generalPracticeFamilyMedicine"
    ],
    "isRegistryMeasure": false
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Diabetes Mellitus (DM) Composite (All or Nothing Scoring) ",
    "description": "Composite of DM-2 (NQF 0059): Diabetes: Homoglobin A1c (HbA1c) Poor Control (<9%) & DM-7 (NQF 0055): Diabetes: Eye Exam ",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "intermediateOutcomeAndProcess",
    "measureId": "dmComposite",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0055 & 0059",
    "isInverse": false,
    "strata": [
      {
        "description": "Percentage of patients 18 - 75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period and who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal or dilated eye exam (no evidence of retinopathy) in the 12 months prior to the measurement period",
        "name": "A1c>9.0%"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "National Committee for Quality Assurance",
    "submissionMethods": [
      "cmsWebInterface"
    ],
    "measureSets": [],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "cmsWebInterface": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Web-Interface-Measures/2017 WI_DM.pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "ACI_PHCDRR_5",
    "title": "Clinical Data Registry Reporting",
    "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.  Earn a 5 % bonus in the advancing care information performance category score for submitting to one or more public health or clinical data registries.",
    "isRequired": false,
    "weight": 5,
    "measureSets": [],
    "isBonus": true,
    "objective": "publicHealthAndClinicalDataRegistryReporting",
    "reportingCategory": "registryBonus",
    "substitutes": [
      "ACI_TRANS_PHCDRR_3"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/aci_specifications/Measure Specifications/MIPS ACI Measure_Clinical Data Registry Reporting.pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "proportion",
    "measureId": "ACI_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": [
      "ACI_TRANS_MR_1"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/aci_specifications/Measure Specifications/MIPS ACI Measure_Clinical Information Reconciliation.pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "ACI_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.  Earn a 5 % bonus in the advancing care information performance category score for submitting to one or more public health or clinical data registries.",
    "isRequired": false,
    "weight": 5,
    "measureSets": [],
    "isBonus": true,
    "objective": "publicHealthAndClinicalDataRegistryReporting",
    "reportingCategory": "registryBonus",
    "substitutes": [],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/aci_specifications/Measure Specifications/MIPS ACI Measure_Electronic Case Reporting.pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "proportion",
    "measureId": "ACI_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": [
      "ACI_LVPP_1",
      "ACI_TRANS_EP_1",
      "ACI_TRANS_LVPP_1"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/aci_specifications/Measure Specifications/MIPS ACI Measure_e-Prescribing.pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "ACI_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": [
      "ACI_TRANS_PHCDRR_1"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/aci_specifications/Measure Specifications/MIPS ACI Measure_Immunization Registry Reporting.pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "proportion",
    "measureId": "ACI_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/aci_specifications/Measure Specifications/MIPS ACI Measure_Patient-Generated Health Data.pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "proportion",
    "measureId": "ACI_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": [
      "ACI_TRANS_PSE_1"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/aci_specifications/Measure Specifications/MIPS ACI Measure_Patient-Specific Education.pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "proportion",
    "measureId": "ACI_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": [
      "ACI_TRANS_PEA_1"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/aci_specifications/Measure Specifications/MIPS ACI Measure_Provide Patient Access.pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "ACI_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.  Earn a 5 % bonus in the advancing care information performance category score for submitting to one or more public health or clinical data registries.",
    "isRequired": false,
    "weight": 5,
    "measureSets": [],
    "isBonus": true,
    "objective": "publicHealthAndClinicalDataRegistryReporting",
    "reportingCategory": "registryBonus",
    "substitutes": [],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/aci_specifications/Measure Specifications/MIPS ACI Measure_Public Health Registry Reporting.pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "proportion",
    "measureId": "ACI_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": [
      "ACI_LVITC_1",
      "ACI_TRANS_HIE_1",
      "ACI_TRANS_LVOTC_1"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/aci_specifications/Measure Specifications/MIPS ACI Measure_Request-Accept Summary of Care.pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "proportion",
    "measureId": "ACI_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": [
      "ACI_TRANS_SM_1"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/aci_specifications/Measure Specifications/MIPS ACI Measure_Secure Messaging.pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "ACI_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": [
      "ACI_TRANS_PPHI_1"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/aci_specifications/Measure Specifications/MIPS ACI Measure_Security Risk Analysis.pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "proportion",
    "measureId": "ACI_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": [
      "ACI_LVOTC_1",
      "ACI_TRANS_HIE_1",
      "ACI_TRANS_LVOTC_1"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/aci_specifications/Measure Specifications/MIPS ACI Measure_Send a Summary of Care.pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "ACI_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.  Earn a 5 % bonus in the advancing care information performance category score for submitting to one or more public health or clinical data registries.",
    "isRequired": false,
    "weight": 5,
    "measureSets": [],
    "isBonus": true,
    "objective": "publicHealthAndClinicalDataRegistryReporting",
    "reportingCategory": "registryBonus",
    "substitutes": [
      "ACI_TRANS_PHCDRR_2"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/aci_specifications/Measure Specifications/MIPS ACI Measure_Syndromic Surveillance Reporting.pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "proportion",
    "measureId": "ACI_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": [
      "ACI_TRANS_PEA_2"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/aci_specifications/Measure Specifications/MIPS ACI Measure_View Download or Transmit (VDT).pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "proportion",
    "measureId": "ACI_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": [
      "ACI_TRANS_LVPP_1",
      "ACI_LVPP_1",
      "ACI_EP_1"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/aci_specifications/Transition Measure Specifications/MIPS 2017 ACI Transition Measure_e-Prescribing.pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "proportion",
    "measureId": "ACI_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": [
      "ACI_TRANS_LVOTC_1",
      "ACI_HIE_1",
      "ACI_LVOTC_1",
      "ACI_HIE_2",
      "ACI_LVITC_1"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/aci_specifications/Transition Measure Specifications/MIPS 2017 ACI Transition Measure_Health Information Exchange.pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "ACI_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": [
      "ACI_PHCDRR_1"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/aci_specifications/Transition Measure Specifications/MIPS 2017 ACI Transition Measure_Immunization Registry Reporting.pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "proportion",
    "measureId": "ACI_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": [
      "ACI_HIE_3"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/aci_specifications/Transition Measure Specifications/MIPS 2017 ACI Transition Measure_Medication Reconciliation.pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "proportion",
    "measureId": "ACI_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": [
      "ACI_PEA_2"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/aci_specifications/Transition Measure Specifications/MIPS 2017 ACI Transition Measure_Patient-Specific Education.pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "proportion",
    "measureId": "ACI_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": [
      "ACI_PEA_1"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/aci_specifications/Transition Measure Specifications/MIPS 2017 ACI Transition Measure_Provide Patient Access.pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "proportion",
    "measureId": "ACI_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": [
      "ACI_CCTPE_2"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/aci_specifications/Transition Measure Specifications/MIPS 2017 ACI Transition Measure_Secure Messaging.pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "ACI_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": [
      "ACI_PPHI_1"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/aci_specifications/Transition Measure Specifications/MIPS 2017 ACI Transition Measure_Security Risk Analysis.pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "ACI_TRANS_PHCDRR_3",
    "title": "Specialized Registry Reporting",
    "description": "The MIPS eligible clinician is in active engagement to submit data to specialized registry.  Earn a 5 % bonus in the advancing care information performance category score for submitting to one or more public health or clinical data registries.",
    "isRequired": false,
    "weight": 5,
    "measureSets": [
      "transition"
    ],
    "isBonus": true,
    "objective": "publicHealthReporting",
    "reportingCategory": "registryBonus",
    "substitutes": [
      "ACI_PHCDRR_5"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/aci_specifications/Transition Measure Specifications/MIPS 2017 ACI Transition Measure_Specialized Registry Reporting.pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "ACI_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.  Earn a 5 % bonus in the advancing care information performance category score for submitting to one or more public health or clinical data registries.",
    "isRequired": false,
    "weight": 5,
    "measureSets": [
      "transition"
    ],
    "isBonus": true,
    "objective": "publicHealthReporting",
    "reportingCategory": "registryBonus",
    "substitutes": [
      "ACI_PHCDRR_2"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/aci_specifications/Transition Measure Specifications/MIPS 2017 ACI Transition Measure_Syndromic Surveillance Reporting.pdf"
    }
  },
  {
    "category": "aci",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "proportion",
    "measureId": "ACI_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": [
      "ACI_CCTPE_1"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/aci_specifications/Transition Measure Specifications/MIPS 2017 ACI Transition Measure_View Download or Transmit (VDT).pdf"
    }
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_EPA_4",
    "cehrtEligible": false,
    "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).",
    "title": "Additional improvements in access as a result of QIN/QIO TA",
    "weight": "medium",
    "subcategoryId": "expandedPracticeAccess"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PSPA_4",
    "cehrtEligible": false,
    "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)",
    "title": "Administration of the AHRQ Survey of Patient Safety Culture",
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PSPA_5",
    "cehrtEligible": false,
    "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.",
    "title": "Annual registration in the Prescription Drug Monitoring Program",
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PM_2",
    "cehrtEligible": true,
    "description": "MIPS eligible clinicians and  groups who prescribe oral Vitamin K antagonist therapy (warfarin) must attest that, in the first performance year, 60 percent or more of their ambulatory care patients receiving warfarin are being managed by one or more of these clinical practice improvement activities: \nPatients are being managed by an anticoagulant management service, that involves systematic and coordinated care*, incorporating comprehensive patient education, systematic INR testing, tracking, follow-up, and patient communication of results and dosing decisions;\n\nPatients are being managed according to validated electronic decision support and clinical management tools that involve systematic and coordinated care, incorporating comprehensive patient education, systematic INR testing, tracking, follow-up, and patient communication of results and dosing decisions;\n\nFor rural or remote patients, patients are managed using remote monitoring or telehealth options that involve systematic and coordinated care, incorporating comprehensive patient education, systematic INR testing, tracking, follow-up, and patient communication of results and dosing decisions; and/or\n\nFor patients who demonstrate motivation, competency, and adherence, patients are managed using either a patient self-testing (PST) or patient-self-management (PSM) program.\n\nThe performance threshold will increase to 75 percent for the second performance year and onward.\nClinicians would attest that, 60 percent for first year, or 75 percent for the second year, of their ambulatory care patients receiving warfarin participated in an anticoagulation management program for at least 90 days during the performance period.\n\n\n",
    "title": "Anticoagulant management improvements",
    "weight": "high",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_CC_12",
    "cehrtEligible": false,
    "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.\n\n",
    "title": "Care coordination agreements that promote improvements in patient tracking across settings",
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_CC_10",
    "cehrtEligible": false,
    "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.).",
    "title": "Care transition documentation practice improvements",
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_CC_11",
    "cehrtEligible": false,
    "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.\n",
    "title": "Care transition standard operational improvements",
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PM_13",
    "cehrtEligible": true,
    "description": "Proactively manage chronic and preventive care for empaneled patients that could include one or more of the following:  \nProvide 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; plan of care for chronic conditions; and advance care planning;\nUse 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;\nUse pre-visit planning to optimize preventive care and team management of patients with chronic conditions;\nUse panel support tools (registry functionality) to identify services due; \nUse 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\nRoutine medication reconciliation.",
    "title": "Chronic care and preventative care management for empanelled patients",
    "weight": "medium",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_CC_5",
    "cehrtEligible": false,
    "description": "Membership and participation in a CMS Partnership for Patients Hospital Improvement Innovation Network.",
    "title": "CMS partner in Patients Hospital Improvement Innovation Networks",
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BE_6",
    "cehrtEligible": false,
    "description": "Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of improvement plan. ",
    "title": "Collection and follow-up on patient experience and satisfaction data on beneficiary engagement",
    "weight": "high",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_EPA_3",
    "cehrtEligible": false,
    "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.  ",
    "title": "Collection and use of patient experience and satisfaction data on access",
    "weight": "medium",
    "subcategoryId": "expandedPracticeAccess"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PSPA_9",
    "cehrtEligible": false,
    "description": "Completion of the American Medical Association's STEPS Forward program.",
    "title": "Completion of the AMA STEPS Forward program",
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PSPA_10",
    "cehrtEligible": false,
    "description": "Completion of training and obtaining an approved waiver for provision of medication-assisted treatment of opioid use disorders using buprenorphine.",
    "title": "Completion of training and receipt of approved waiver for provision opioid medication-assisted treatments",
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PSPA_6",
    "cehrtEligible": false,
    "description": "Clinicians would attest that, 60 percent for first year, or 75 percent for the second year, of consultation of prescription drug monitoring program prior to the issuance of a Controlled Substance Schedule II (CSII) opioid prescription that lasts for longer than 3 days. ",
    "title": "Consultation of the Prescription Drug Monitoring program",
    "weight": "high",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BMH_4",
    "cehrtEligible": false,
    "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.",
    "title": "Depression screening",
    "weight": "medium",
    "subcategoryId": "behavioralAndMentalHealth"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BMH_1",
    "cehrtEligible": false,
    "description": "Diabetes screening for people with schizophrenia or bipolar disease who are using antipsychotic medication.",
    "title": "Diabetes screening ",
    "weight": "medium",
    "subcategoryId": "behavioralAndMentalHealth"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BMH_8",
    "cehrtEligible": true,
    "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).",
    "title": "Electronic Health Record Enhancements for BH data capture",
    "weight": "medium",
    "subcategoryId": "behavioralAndMentalHealth"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PM_5",
    "cehrtEligible": false,
    "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. ",
    "title": "Engagement of community for health status improvement",
    "weight": "medium",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_AHE_1",
    "cehrtEligible": false,
    "description": "Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare. ",
    "title": "Engagement of new Medicaid patients and follow-up",
    "weight": "high",
    "subcategoryId": "achievingHealthEquity"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BE_15",
    "cehrtEligible": true,
    "description": "Engage patients, family and caregivers in developing a plan of care and prioritizing their goals for action, documented in the certified EHR technology.",
    "title": "Engagement of patients, family and caregivers in developing a plan of care ",
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BE_4",
    "cehrtEligible": true,
    "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.",
    "title": "Engagement of patients through implementation of improvements in patient portal",
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BE_3",
    "cehrtEligible": false,
    "description": "Engagement with a Quality Innovation Network-Quality Improvement Organization, which may include participation in self-management training programs such as diabetes.",
    "title": "Engagement with QIN-QIO to implement self-management training programs",
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BE_14",
    "cehrtEligible": false,
    "description": "Engage patients and families to guide improvement in the system of care.",
    "title": "Engage patients and families to guide improvement in the system of care.",
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BE_5",
    "cehrtEligible": false,
    "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",
    "title": "Enhancements/regular updates to practice websites/tools that also include considerations for patients with cognitive disabilities",
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BE_16",
    "cehrtEligible": false,
    "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.",
    "title": "Evidenced-based techniques to promote self-management into usual care",
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PM_4",
    "cehrtEligible": true,
    "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.\n\n",
    "title": "Glycemic management services",
    "weight": "high",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_CC_3",
    "cehrtEligible": false,
    "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.",
    "title": "Implementation of additional activity as a result of TA for improving care coordination",
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PSPA_17",
    "cehrtEligible": false,
    "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.\n",
    "title": "Implementation of analytic capabilities to manage total cost of care for practice population",
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PSPA_15",
    "cehrtEligible": false,
    "description": "Implementation of an antibiotic stewardship program that measures the appropriate use of antibiotics for several different conditions (URI Rx in children, diagnosis of pharyngitis, Bronchitis Rx in adults)  according to clinical guidelines for diagnostics and therapeutics",
    "title": "Implementation of antibiotic stewardship program",
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BMH_6",
    "cehrtEligible": false,
    "description": "Integration facilitation, and promotion of the colocation of mental health services in primary and/or non-primary clinical care settings.",
    "title": "Implementation of co-location PCP and MH services",
    "weight": "high",
    "subcategoryId": "behavioralAndMentalHealth"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BE_20",
    "cehrtEligible": false,
    "description": "Provide condition-specific chronic disease self-management support programs or coaching or link patients to those programs in the community.",
    "title": "Implementation of condition-specific chronic disease self-management support programs",
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_CC_8",
    "cehrtEligible": true,
    "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).",
    "title": "Implementation of documentation improvements for practice/process improvements",
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PM_15",
    "cehrtEligible": true,
    "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.\n",
    "title": "Implementation of episodic care management practice improvements",
    "weight": "medium",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PSPA_21",
    "cehrtEligible": false,
    "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).",
    "title": "Implementation of fall screening and assessment programs",
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PSPA_19",
    "cehrtEligible": false,
    "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:  \nTrain all staff in quality improvement methods; \nIntegrate practice change/quality improvement into staff duties;\nEngage all staff in identifying and testing practices changes;\nDesignate regular team meetings to review data and plan improvement cycles;\nPromote transparency and accelerate improvement by sharing practice level and panel level quality of care, patient experience and utilization data with staff; and/or\nPromote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families.\n",
    "title": "Implementation of formal quality improvement methods, practice changes or other practice improvement processes",
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_CC_2",
    "cehrtEligible": false,
    "description": "Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.",
    "title": "Implementation of improvements that contribute to more timely communication of test results",
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BMH_7",
    "cehrtEligible": true,
    "description": "Offer integrated behavioral health services to support patients with behavioral health needs, dementia, and poorly controlled chronic conditions that could include one or more of the following:\nUse evidence-based treatment protocols and treatment to goal where appropriate;\nUse evidence-based screening and case finding strategies to identify individuals at risk and in need of services;\nEnsure regular communication and coordinated workflows between eligible clinicians in primary care and behavioral health;\nConduct regular case reviews for at-risk or unstable patients and those who are not responding to treatment;\nUse of a registry or  certified health information technology  functionality to support active care management and outreach to patients in treatment; and/or\nIntegrate behavioral health and medical care plans and facilitate integration through co-location of services when feasible.\n",
    "title": "Implementation of integrated PCBH model",
    "weight": "high",
    "subcategoryId": "behavioralAndMentalHealth"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PM_16",
    "cehrtEligible": true,
    "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.\n",
    "title": "Implementation of medication management practice improvements",
    "weight": "medium",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PM_14",
    "cehrtEligible": true,
    "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.\n",
    "title": "Implementation of methodologies for improvements in longitudinal care management for high risk patients",
    "weight": "medium",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_CC_9",
    "cehrtEligible": true,
    "description": "Implementation of practices/processes to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s). ",
    "title": "Implementation of practices/processes for developing regular individual care plans",
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_CC_1",
    "cehrtEligible": true,
    "description": "Performance of regular practices that include providing specialist reports back to the referring MIPS eligible clinician or  group to close the referral loop or where the referring MIPS eligible clinician or   group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the certified EHR technology.",
    "title": "Implementation of use of specialist reports back to referring clinician or group to close referral loop",
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BE_21",
    "cehrtEligible": false,
    "description": "Provide self-management materials at an appropriate literacy level and in an appropriate language.",
    "title": "Improved practices that disseminate appropriate self-management materials",
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BE_22",
    "cehrtEligible": false,
    "description": "Provide a pre-visit development of a shared visit agenda with the patient.",
    "title": "Improved practices that engage patients pre-visit",
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BE_23",
    "cehrtEligible": false,
    "description": "Provide coaching between visits with follow-up on care plan and goals.",
    "title": "Integration of patient coaching practices between visits",
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PSPA_20",
    "cehrtEligible": false,
    "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.\n",
    "title": "Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes",
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_AHE_4",
    "cehrtEligible": false,
    "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).",
    "title": "Leveraging a QCDR for use of standard questionnaires",
    "weight": "medium",
    "subcategoryId": "achievingHealthEquity"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_AHE_3",
    "cehrtEligible": false,
    "description": "Participation in a QCDR, demonstrating performance of activities for promoting use of patient-reported outcome (PRO) tools and corresponding collection of PRO data (e.g., use of PQH-2 or PHQ-9 and PROMIS instruments).",
    "title": "Leveraging a QCDR to promote use of patient-reported outcome tools",
    "weight": "medium",
    "subcategoryId": "achievingHealthEquity"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_AHE_2",
    "cehrtEligible": true,
    "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.",
    "title": "Leveraging a QCDR to standardize processes for screening",
    "weight": "medium",
    "subcategoryId": "achievingHealthEquity"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BMH_5",
    "cehrtEligible": false,
    "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. ",
    "title": "MDD prevention and treatment interventions",
    "weight": "medium",
    "subcategoryId": "behavioralAndMentalHealth"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PSPA_18",
    "cehrtEligible": false,
    "description": "Measure and improve quality at the practice and panel level that could include one or more of the following:\n\nRegularly 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\nUse relevant data sources to create benchmarks and goals for performance at the practice level and panel level.\n\n",
    "title": "Measurement and improvement at the practice and panel level",
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PSPA_3",
    "cehrtEligible": false,
    "description": "For eligible professionals not participating in Maintenance of Certification (MOC) Part IV, new engagement for MOC Part IV, such as IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS(R)",
    "title": "Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS(R) or other similar activity.",
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_ERP_2",
    "cehrtEligible": false,
    "description": "Participation in domestic or international humanitarian volunteer work. Activities that simply involve registration are not sufficient.  MIPS eligible clinicians attest to domestic or international humanitarian volunteer work for a period of a continuous 60 days or greater.",
    "title": "Participation in a 60-day or greater effort to support domestic or international humanitarian needs.",
    "weight": "high",
    "subcategoryId": "emergencyResponseAndPreparedness"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PSPA_1",
    "cehrtEligible": false,
    "description": "Participation in an AHRQ-listed patient safety organization. ",
    "title": "Participation in an AHRQ-listed patient safety organization. ",
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BE_8",
    "cehrtEligible": false,
    "description": "Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive. ",
    "title": "Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive. ",
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BE_10",
    "cehrtEligible": false,
    "description": "Participation in a QCDR, that promotes implementation of patient self-action plans. ",
    "title": "Participation in a QCDR, that promotes implementation of patient self-action plans. ",
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BE_7",
    "cehrtEligible": false,
    "description": "Participation in a QCDR, that promotes use of patient engagement tools. ",
    "title": "Participation in a QCDR, that promotes use of patient engagement tools. ",
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BE_11",
    "cehrtEligible": false,
    "description": "Participation in a QCDR, that promotes use of processes and tools that engage patients for adherence to treatment plan. ",
    "title": "Participation in a QCDR, that promotes use of processes and tools that engage patients for adherence to treatment plan. ",
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PSPA_14",
    "cehrtEligible": false,
    "description": "Participation in other quality improvement programs such as Bridges to Excellence",
    "title": "Participation in Bridges to Excellence or other similar program",
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PSPA_11",
    "cehrtEligible": false,
    "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).",
    "title": "Participation in CAHPS or other supplemental questionnaire",
    "weight": "high",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PM_8",
    "cehrtEligible": false,
    "description": " Participation in CMMI models such as the Million Hearts Cardiovascular Risk Reduction Model",
    "title": "Participation in CMMI models such as Million Hearts Campaign",
    "weight": "medium",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PSPA_13",
    "cehrtEligible": false,
    "description": "Participation in Joint Commission Ongoing Professional Practice Evaluation initiative",
    "title": "Participation in Joint Commission Evaluation Initiative",
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PSPA_2",
    "cehrtEligible": false,
    "description": "Participation in Maintenance of Certification (MOC) Part IV 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.",
    "title": "Participation in MOC Part IV",
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PM_9",
    "cehrtEligible": false,
    "description": "Participation in research that identifies interventions, tools or processes that can improve a targeted patient population.",
    "title": "Participation in population health research",
    "weight": "medium",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PSPA_12",
    "cehrtEligible": false,
    "description": "Participation in designated private payer clinical practice improvement activities.",
    "title": "Participation in private payer CPIA",
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PM_1",
    "cehrtEligible": false,
    "description": " Participation in a systematic anticoagulation program (coagulation clinic, patient self-reporting program, patient self-management program)for 60 percent of practice patients in year 1 and 75 percent of practice patients in year 2 who receive anti-coagulation medications (warfarin or other coagulation cascade inhibitors). ",
    "title": "Participation in systematic anticoagulation program",
    "weight": "high",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_ERP_1",
    "cehrtEligible": false,
    "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.",
    "title": "Participation on Disaster Medical Assistance Team, registered for 6 months.",
    "weight": "medium",
    "subcategoryId": "emergencyResponseAndPreparedness"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PM_12",
    "cehrtEligible": false,
    "description": "Empanel (assign responsibility for) the total population, linking each patient to a MIPS eligible clinician or group or care team.\n\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. \n\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.",
    "title": "Population empanelment",
    "weight": "medium",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_CC_13",
    "cehrtEligible": true,
    "description": "Ensure that there is bilateral exchange of necessary patient information to guide patient care that could include one or more of the following: \n\nParticipate in a Health Information Exchange if available; and/or\n\nUse structured referral notes.\n",
    "title": "Practice improvements for bilateral exchange of patient information",
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_CC_14",
    "cehrtEligible": false,
    "description": "Develop pathways to neighborhood/community-based resources to support patient health goals that could include one or more of the following: \n\nMaintain 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/or\n\nProvide a guide to available community resources.\n",
    "title": "Practice improvements that engage community resources to support patient health goals",
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_EPA_1",
    "cehrtEligible": true,
    "description": "Provide 24/7 access to MIPS eligible clinicians,  groups, or care teams for advice about urgent and emergent care (e.g., 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:\nExpanded 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\nUse 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\n\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\n\n",
    "title": "Provide 24/7 access to eligible clinicians or groups who have  real-time access to patient's medical record",
    "weight": "high",
    "subcategoryId": "expandedPracticeAccess"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BE_18",
    "cehrtEligible": false,
    "description": "Provide peer-led support for self-management.",
    "title": "Provide peer-led support for self-management.",
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BE_13",
    "cehrtEligible": false,
    "description": "Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.",
    "title": "Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.",
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PM_11",
    "cehrtEligible": false,
    "description": "Implementation of regular reviews of targeted patient population needs which includes access to reports that show unique characteristics of eligible professional'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.",
    "title": "Regular review practices in place on targeted patient population needs",
    "weight": "medium",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_CC_7",
    "cehrtEligible": false,
    "description": "Implementation of regular care coordination training. ",
    "title": "Regular training in care coordination",
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PM_3",
    "cehrtEligible": false,
    "description": "Participating in a Rural Health Clinic (RHC), Indian Health Service (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.",
    "title": "RHC, IHS or FQHC quality improvement activities",
    "weight": "high",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_CC_4",
    "cehrtEligible": false,
    "description": "Participation in the CMS Transforming Clinical Practice Initiative.",
    "title": "TCPI participation",
    "weight": "high",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BMH_2",
    "cehrtEligible": false,
    "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.",
    "title": "Tobacco use",
    "weight": "medium",
    "subcategoryId": "behavioralAndMentalHealth"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BMH_3",
    "cehrtEligible": false,
    "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. ",
    "title": " Unhealthy alcohol use",
    "weight": "medium",
    "subcategoryId": "behavioralAndMentalHealth"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BE_12",
    "cehrtEligible": false,
    "description": "Use evidence-based decision aids to support shared decision-making.",
    "title": "Use evidence-based decision aids to support shared decision-making.",
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BE_19",
    "cehrtEligible": false,
    "description": "Use group visits for common chronic conditions (e.g., diabetes).",
    "title": "Use group visits for common chronic conditions (e.g., diabetes).",
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BE_1",
    "cehrtEligible": true,
    "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.",
    "title": "Use of certified EHR to capture patient reported outcomes",
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PSPA_16",
    "cehrtEligible": true,
    "description": "Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs.",
    "title": "Use of decision support and standardized treatment protocols",
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PSPA_8",
    "cehrtEligible": false,
    "description": " Use of tools that assist specialty practices in tracking specific measures that are meaningful to their practice, such as use of the Surgical Risk Calculator.  ",
    "title": "Use of patient safety tools",
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PSPA_7",
    "cehrtEligible": false,
    "description": "Use of QCDR data, for ongoing practice assessment and improvements in patient safety. ",
    "title": "Use of QCDR data for ongoing practice assessment and improvements",
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PM_10",
    "cehrtEligible": false,
    "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). ",
    "title": "Use of QCDR data for quality improvement such as comparative analysis reports across patient populations",
    "weight": "medium",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PM_7",
    "cehrtEligible": false,
    "description": " Use of a QCDR to generate regular feedback reports that summarize local practice patterns and treatment outcomes, including for vulnerable populations.",
    "title": "Use of QCDR for feedback reports that incorporate population health ",
    "weight": "high",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BE_9",
    "cehrtEligible": false,
    "description": " Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement. ",
    "title": " Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement. ",
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_CC_6",
    "cehrtEligible": false,
    "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).",
    "title": "Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination",
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BE_2",
    "cehrtEligible": false,
    "description": "Participation in a QCDR, demonstrating performance of activities that promote implementation of shared clinical decision making capabilities.",
    "title": "Use of QCDR to support clinical decision making",
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_EPA_2",
    "cehrtEligible": false,
    "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.  ",
    "title": "Use of telehealth services that expand practice access",
    "weight": "medium",
    "subcategoryId": "expandedPracticeAccess"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_PM_6",
    "cehrtEligible": false,
    "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.",
    "title": "Use of toolsets or other resources to close healthcare disparities across communities",
    "weight": "medium",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "boolean",
    "measureId": "IA_BE_17",
    "cehrtEligible": false,
    "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).",
    "title": "Use of tools to assist patient self-management",
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "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": "singlePerformanceRate",
    "title": "Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use",
    "description": "Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy",
    "nationalQualityStrategyDomain": "ECR",
    "measureType": "process",
    "measureId": "093",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0654",
    "isInverse": false,
    "strata": [
      {
        "description": "Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy",
        "name": "AOE"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "American Academy of Otolaryngology-Head and Neck Surgery",
    "submissionMethods": [
      "claims",
      "registry"
    ],
    "measureSets": [
      "emergencyMedicine",
      "otolaryngology",
      "generalPracticeFamilyMedicine",
      "pediatrics"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_093_Claims.pdf",
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_093_Registry.pdf"
    },
    "eligibilityOptions": [
      {
        "diagnosisCodes": [
          "H60.00",
          "H60.01",
          "H60.02",
          "H60.03",
          "H60.10",
          "H60.11",
          "H60.12",
          "H60.13",
          "H60.311",
          "H60.312",
          "H60.313",
          "H60.319",
          "H60.321",
          "H60.322",
          "H60.323",
          "H60.329",
          "H60.331",
          "H60.332",
          "H60.333",
          "H60.339",
          "H60.391",
          "H60.392",
          "H60.393",
          "H60.399",
          "H60.501",
          "H60.502",
          "H60.503",
          "H60.509",
          "H60.511",
          "H60.512",
          "H60.513",
          "H60.519",
          "H60.521",
          "H60.522",
          "H60.523",
          "H60.529",
          "H60.531",
          "H60.532",
          "H60.533",
          "H60.539",
          "H60.541",
          "H60.542",
          "H60.543",
          "H60.549",
          "H60.551",
          "H60.552",
          "H60.553",
          "H60.559",
          "H60.591",
          "H60.592",
          "H60.593",
          "H60.599",
          "H61.90",
          "H61.91",
          "H61.92",
          "H61.93",
          "H62.40",
          "H62.41",
          "H62.42",
          "H62.43",
          "H62.8X1",
          "H62.8X2",
          "H62.8X3",
          "H62.8X9"
        ],
        "minAge": 2,
        "procedureCodes": [
          {
            "code": "99201",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99202",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99203",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99204",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99205",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99212",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99213",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99214",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99215",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99281"
          },
          {
            "code": "99282"
          },
          {
            "code": "99283"
          },
          {
            "code": "99284"
          },
          {
            "code": "99285"
          },
          {
            "code": "99304"
          },
          {
            "code": "99305"
          },
          {
            "code": "99306"
          },
          {
            "code": "99307",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99308",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99309",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99310",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99324"
          },
          {
            "code": "99325"
          },
          {
            "code": "99326"
          },
          {
            "code": "99327"
          },
          {
            "code": "99328"
          },
          {
            "code": "99334"
          },
          {
            "code": "99335"
          },
          {
            "code": "99336"
          },
          {
            "code": "99341"
          },
          {
            "code": "99342"
          },
          {
            "code": "99343"
          },
          {
            "code": "99344"
          },
          {
            "code": "99345"
          },
          {
            "code": "99347"
          },
          {
            "code": "99348"
          },
          {
            "code": "99349"
          },
          {
            "code": "99350"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      }
    ],
    "performanceOptions": [
      {
        "optionType": "eligiblePopulationException",
        "qualityCodes": [
          {
            "code": "4131F",
            "modifierExclusions": [
              "2P",
              "3P",
              "8P"
            ],
            "modifiers": [
              "1P"
            ]
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "optionType": "performanceNotMet",
        "qualityCodes": [
          {
            "code": "4131F",
            "modifierExclusions": [
              "1P",
              "2P",
              "3P",
              "8P"
            ]
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "optionType": "performanceMet",
        "qualityCodes": [
          {
            "code": "4132F",
            "modifierExclusions": [
              "1P",
              "2P",
              "3P",
              "8P"
            ]
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      }
    ]
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Acute Otitis Externa (AOE): Topical Therapy",
    "description": "Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "process",
    "measureId": "091",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0653",
    "isInverse": false,
    "strata": [
      {
        "description": "Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations",
        "name": "AOE"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "American Academy of Otolaryngology-Head and Neck Surgery",
    "submissionMethods": [
      "claims",
      "registry"
    ],
    "measureSets": [
      "emergencyMedicine",
      "otolaryngology",
      "pediatrics"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_091_Claims.pdf",
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_091_Registry.pdf"
    },
    "eligibilityOptions": [
      {
        "diagnosisCodes": [
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          "H60.01",
          "H60.02",
          "H60.03",
          "H60.10",
          "H60.11",
          "H60.12",
          "H60.13",
          "H60.311",
          "H60.312",
          "H60.313",
          "H60.319",
          "H60.321",
          "H60.322",
          "H60.323",
          "H60.329",
          "H60.331",
          "H60.332",
          "H60.333",
          "H60.339",
          "H60.391",
          "H60.392",
          "H60.393",
          "H60.399",
          "H60.501",
          "H60.502",
          "H60.503",
          "H60.509",
          "H60.511",
          "H60.512",
          "H60.513",
          "H60.519",
          "H60.521",
          "H60.522",
          "H60.523",
          "H60.529",
          "H60.531",
          "H60.532",
          "H60.533",
          "H60.539",
          "H60.541",
          "H60.542",
          "H60.543",
          "H60.549",
          "H60.551",
          "H60.552",
          "H60.553",
          "H60.559",
          "H60.591",
          "H60.592",
          "H60.593",
          "H60.599",
          "H61.90",
          "H61.91",
          "H61.92",
          "H61.93",
          "H62.40",
          "H62.41",
          "H62.42",
          "H62.43",
          "H62.8x1",
          "H62.8x2",
          "H62.8x3",
          "H62.8x9"
        ],
        "minAge": 2,
        "procedureCodes": [
          {
            "code": "99201",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99202",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99203",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99204",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99205",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99212",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99213",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99214",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99215",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99281"
          },
          {
            "code": "99282"
          },
          {
            "code": "99283"
          },
          {
            "code": "99284"
          },
          {
            "code": "99285"
          },
          {
            "code": "99304"
          },
          {
            "code": "99305"
          },
          {
            "code": "99306"
          },
          {
            "code": "99307",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99308",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99309",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99310",
            "modifierExclusions": [
              "GQ",
              "GT"
            ]
          },
          {
            "code": "99324"
          },
          {
            "code": "99325"
          },
          {
            "code": "99326"
          },
          {
            "code": "99327"
          },
          {
            "code": "99328"
          },
          {
            "code": "99334"
          },
          {
            "code": "99335"
          },
          {
            "code": "99336"
          },
          {
            "code": "99341"
          },
          {
            "code": "99342"
          },
          {
            "code": "99343"
          },
          {
            "code": "99344"
          },
          {
            "code": "99345"
          },
          {
            "code": "99347"
          },
          {
            "code": "99348"
          },
          {
            "code": "99349"
          },
          {
            "code": "99350"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      }
    ],
    "performanceOptions": [
      {
        "optionType": "eligiblePopulationException",
        "qualityCodes": [
          {
            "code": "4130F",
            "modifierExclusions": [
              "2P",
              "3P",
              "8P"
            ],
            "modifiers": [
              "1P"
            ]
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "optionType": "eligiblePopulationException",
        "qualityCodes": [
          {
            "code": "4130F",
            "modifierExclusions": [
              "1P",
              "3P",
              "8P"
            ],
            "modifiers": [
              "2P"
            ]
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "optionType": "performanceMet",
        "qualityCodes": [
          {
            "code": "4130F",
            "modifierExclusions": [
              "1P",
              "2P",
              "3P",
              "8P"
            ]
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "optionType": "performanceNotMet",
        "qualityCodes": [
          {
            "code": "4130F",
            "modifierExclusions": [
              "1P",
              "2P",
              "3P"
            ],
            "modifiers": [
              "8P"
            ]
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      }
    ]
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "multiPerformanceRate",
    "title": "ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication",
    "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.  \na. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase.\nb. 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.\n",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "process",
    "measureId": "366",
    "eMeasureId": "CMS136v6",
    "nqfEMeasureId": null,
    "nqfId": "0108",
    "isInverse": false,
    "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": {
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          "denominatorUuid": "815F709E-9703-4A6E-860F-CB0096A98B71",
          "numeratorUuid": "341DBA96-D1CC-409F-99D9-8AB80D03B4A8",
          "denominatorExclusionUuid": "FE028D3B-7AB5-418B-A90C-CCFE76F25078"
        },
        "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": "9FC61BF5-1EBD-44DE-ADCB-64E70FD3C0A5",
          "denominatorUuid": "62FDAE01-000B-40A0-9C74-4A803BA37A96",
          "numeratorUuid": "5097B983-9C47-4F28-9194-C795F42053AF",
          "denominatorExclusionUuid": "425772D2-6437-4F33-9B1E-349E1C6587D9"
        },
        "name": "visitAndFollowups"
      }
    ],
    "isHighPriority": false,
    "primarySteward": "National Committee for Quality Assurance",
    "submissionMethods": [
      "electronicHealthRecord",
      "registry"
    ],
    "measureSets": [
      "mentalBehavioralHealth",
      "pediatrics"
    ],
    "eMeasureUuid": "40280381-51f0-825b-0152-22a639d81762",
    "overallAlgorithm": "simpleAverage",
    "isRegistryMeasure": false,
    "measureSpecification": {
      "electronicHealthRecord": "https://qpp.cms.gov/docs/ecqm-specs/2017/EC_CMS136v6_NQF0108_ADHD_FollowUp/CMS136v6.html"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Adherence to Antipsychotic Medications For Individuals with Schizophrenia",
    "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": "PS",
    "measureType": "intermediateOutcome",
    "measureId": "383",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "1879",
    "isInverse": false,
    "strata": [
      {
        "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)",
        "name": "schizophrenia"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "Health Services Advisory Group ",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "mentalBehavioralHealth"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_383_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "multiPerformanceRate",
    "title": "Adult Kidney Disease: Blood Pressure Management",
    "description": "Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) with a blood pressure < 140/90 mmHg OR >= 140/90 mmHg with a documented plan of care",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "intermediateOutcome",
    "measureId": "122",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "description": "Percentage of patient visits with blood pressure results < 140/90 mmHg",
        "name": "<140/90mmHg"
      },
      {
        "description": "Percentage of patient visits with blood pressure results ≥ 140/90 mmHg and plan of care",
        "name": "planOfCare"
      },
      {
        "description": "Overall percentage of patient visits with blood pressure results < 140/90 mmHg and ≥ 140/90 mmHg with a documented plan of care Eligible clinicians should continue to report the measure as specified, with no additional steps needed to account for multiple performance rates.",
        "name": "overall"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "Renal Physicians Association",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [],
    "overallAlgorithm": "overallStratumOnly",
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_122_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis",
    "description": "Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) who initiate maintenance hemodialysis during the measurement period, whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "outcome",
    "measureId": "329",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": true,
    "strata": [
      {
        "description": "Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) who initiate maintenance hemodialysis during the measurement period, whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated",
        "name": "ESRD"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "Renal Physicians Association",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_329_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days",
    "description": "Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving maintenance hemodialysis for greater than or equal to 90 days whose mode of vascular access is a catheter",
    "nationalQualityStrategyDomain": "PS",
    "measureType": "outcome",
    "measureId": "330",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": true,
    "strata": [
      {
        "description": "Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving maintenance hemodialysis for greater than or equal to 90 days whose mode of vascular access is a catheter",
        "name": "ESRD"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "Renal Physicians Association",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_330_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Adult Kidney Disease: Referral to Hospice",
    "description": "Percentage of patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care",
    "nationalQualityStrategyDomain": "PCCEO",
    "measureType": "process",
    "measureId": "403",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "description": "Percentage of patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care",
        "name": "ESRD"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "Renal Physicians Association",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_403_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions",
    "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": "CCC",
    "measureType": "process",
    "measureId": "325",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "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",
        "name": "comorbid"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "American Psychiatric Association",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "mentalBehavioralHealth"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_325_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Adult Major Depressive Disorder (MDD): Suicide Risk Assessment",
    "description": "Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "process",
    "measureId": "107",
    "eMeasureId": "CMS161v5",
    "nqfEMeasureId": null,
    "nqfId": "0104",
    "isInverse": false,
    "strata": [
      {
        "description": "Patients with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified",
        "eMeasureUuids": {
          "initialPopulationUuid": "9CDC88D7-31DA-44F1-9348-CFDD29F4B20B",
          "denominatorUuid": "1EC810C4-E6D2-4ED6-AE02-A0BF4D675F05",
          "numeratorUuid": "693493EC-2E8E-447C-88A3-FC93AD771AB9"
        },
        "name": "assessedSuicideRisk"
      }
    ],
    "isHighPriority": false,
    "primarySteward": "Physician Consortium for Performance Improvement",
    "submissionMethods": [
      "electronicHealthRecord",
      "registry"
    ],
    "measureSets": [],
    "eMeasureUuid": "40280381-503f-a1fc-0150-de8350a220c3",
    "isRegistryMeasure": false,
    "measureSpecification": {
      "electronicHealthRecord": "https://qpp.cms.gov/docs/ecqm-specs/2017/EC_CMS161v5_NQF0104_MDD_SuicideRisk/CMS161v5.html"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery",
    "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": "ECC",
    "measureType": "outcome",
    "measureId": "384",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "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",
        "name": "retinalDetachment"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "American Academy of Ophthalmology",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "ophthalmology"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_384_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery",
    "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": "ECC",
    "measureType": "outcome",
    "measureId": "385",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "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",
        "name": "retinalDetachment"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "American Academy of Ophthalmology",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "ophthalmology"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_385_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
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    "nqfId": "0006 & 0005",
    "isInverse": false,
    "strata": [],
    "isHighPriority": true,
    "primarySteward": "Agency for Healthcare Research & Quality",
    "submissionMethods": [
      "certifiedSurveyVendor"
    ],
    "measureSets": [
      "generalPracticeFamilyMedicine"
    ],
    "isRegistryMeasure": false
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Cardiac Rehabilitation Patient Referral from an Outpatient Setting",
    "description": "Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program",
    "nationalQualityStrategyDomain": "CCC",
    "measureType": "process",
    "measureId": "243",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0643",
    "isInverse": false,
    "strata": [
      {
        "description": "Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program Definition: Referral - A referral is defined as an official communication between the health care provider and the patient to recommend and carry out a referral order to an outpatient CR program. This includes the provision of all necessary information to the patient that will allow the patient to enroll in an outpatient CR program. This also includes a written or electronic communication between the healthcare provider or healthcare system and the cardiac rehabilitation program that includes the patient's enrollment information for the program. A hospital discharge summary or office note may potentially be formatted to include the necessary patient information to communicate to the CR program (the patient’s cardiovascular history, testing, and treatments, for instance). According to standards of practice for cardiac rehabilitation programs, care coordination communications are sent to the referring provider, including any issues regarding treatment changes, adverse treatment responses, or new non-emergency condition (new symptoms, patient care questions, etc.) that need attention by the referring provider. These communications also include a progress report once the patient has completed the program. All communications must maintain an appropriate level of confidentiality as outlined by the 1996 Health Insurance Portability and Accountability Act (HIPAA). Note: A patient with a qualifying diagnosis should have a referral to CR within the subsequent 12 months. In the event that the patient has a second (recurrent) qualifying event before the original 12 month “referral” period has ended, a new 12 month “referral” period for CR referral starts at the time of the second qualifying event, since the patient again becomes eligible for CR at that time.",
        "name": "outpatient"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "American College of Cardiology Foundation",
    "submissionMethods": [
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    "measureSets": [],
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    "measureSpecification": {
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    }
  },
  {
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    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients",
    "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 reporting period",
    "nationalQualityStrategyDomain": "ECR",
    "measureType": "efficiency",
    "measureId": "322",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": true,
    "strata": [
      {
        "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 reporting period",
        "name": "preoperative"
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    ],
    "isHighPriority": true,
    "primarySteward": "American College of Cardiology",
    "submissionMethods": [
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    ],
    "measureSets": [
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    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_322_Registry.pdf"
    }
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    "category": "quality",
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    "metricType": "singlePerformanceRate",
    "title": "Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)",
    "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 patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status",
    "nationalQualityStrategyDomain": "ECR",
    "measureType": "efficiency",
    "measureId": "323",
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    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": true,
    "strata": [
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        "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 patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status",
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    ],
    "measureSets": [
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    ],
    "isRegistryMeasure": false,
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      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_323_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients",
    "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": "ECR",
    "measureType": "efficiency",
    "measureId": "324",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": true,
    "strata": [
      {
        "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",
        "name": "CHD"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "American College of Cardiology",
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    "measureSets": [
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    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_324_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
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    "metricType": "singlePerformanceRate",
    "title": "Care Plan",
    "description": "Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan",
    "nationalQualityStrategyDomain": "CCC",
    "measureType": "process",
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    "nqfId": "0326",
    "isInverse": false,
    "strata": [
      {
        "description": "Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan",
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      }
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    "isHighPriority": true,
    "primarySteward": "National Committee for Quality Assurance",
    "submissionMethods": [
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    ],
    "measureSets": [
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      "cardiology",
      "emergencyMedicine",
      "gastroenterology",
      "generalSurgery",
      "generalOncology",
      "hospitalists",
      "neurology",
      "obstetricsGynecology",
      "ophthalmology",
      "orthopedicSurgery",
      "otolaryngology",
      "physicalMedicine",
      "preventiveMedicine",
      "rheumatology",
      "thoracicSurgery",
      "urology",
      "vascularSurgery",
      "mentalBehavioralHealth",
      "plasticSurgery",
      "generalPracticeFamilyMedicine"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_047_Claims.pdf",
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    "eligibilityOptions": [
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            "code": "99201"
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            "code": "99202"
          },
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            "code": "99203"
          },
          {
            "code": "99204"
          },
          {
            "code": "99205"
          },
          {
            "code": "99212"
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          {
            "code": "99213"
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          {
            "code": "99214"
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            "code": "99218"
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            "code": "99222"
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            "code": "99223"
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            "code": "99231"
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            "code": "99232"
          },
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            "code": "99233"
          },
          {
            "code": "99234"
          },
          {
            "code": "99235"
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          {
            "code": "99236"
          },
          {
            "code": "99291",
            "placesOfServiceExclusions": [
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          },
          {
            "code": "99304"
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          {
            "code": "99305"
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          {
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            "code": "99307"
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          {
            "code": "99308"
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            "code": "99309"
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            "code": "99310"
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            "code": "99324"
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            "code": "99325"
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          {
            "code": "99326"
          },
          {
            "code": "99327"
          },
          {
            "code": "99328"
          },
          {
            "code": "99334"
          },
          {
            "code": "99335"
          },
          {
            "code": "99336"
          },
          {
            "code": "99337"
          },
          {
            "code": "99341"
          },
          {
            "code": "99342"
          },
          {
            "code": "99343"
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          {
            "code": "99344"
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          {
            "code": "99345"
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          {
            "code": "99347"
          },
          {
            "code": "99348"
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          {
            "code": "99349"
          },
          {
            "code": "99350"
          },
          {
            "code": "G0402"
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          {
            "code": "G0438"
          },
          {
            "code": "G0439"
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        ],
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    "performanceOptions": [
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        ],
        "submissionMethods": [
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      },
      {
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        "submissionMethods": [
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      },
      {
        "optionType": "performanceNotMet",
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        ],
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              "8P"
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    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery",
    "description": "Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "outcome",
    "measureId": "191",
    "eMeasureId": "CMS133v5",
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    "nqfId": "0565",
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    "strata": [
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        "description": "Patients who had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following cataract surgery",
        "name": "cataract",
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    "title": "Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures",
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    "nationalQualityStrategyDomain": "PS",
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        "description": "Patients who had one or more specified operative procedures for any of the following major complications within 30 days following cataract surgery: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence",
        "name": "cataract",
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    "title": "Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery",
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    "nationalQualityStrategyDomain": "PCCEO",
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        "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",
        "name": "cataract"
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    ],
    "isHighPriority": true,
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  },
  {
    "category": "quality",
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    "title": "Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery",
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    "nationalQualityStrategyDomain": "PCCEO",
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    "strata": [
      {
        "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",
        "name": "cataract"
      }
    ],
    "isHighPriority": true,
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    ],
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  },
  {
    "category": "quality",
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    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Cataract Surgery: Difference Between Planned and Final Refraction",
    "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": "ECC",
    "measureType": "outcome",
    "measureId": "389",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "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",
        "name": "cataract"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "American Academy of Ophthalmology",
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  },
  {
    "category": "quality",
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    "title": "Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy)",
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    "nationalQualityStrategyDomain": "PS",
    "measureType": "outcome",
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    "strata": [
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        "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",
        "name": "cataract"
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    ],
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    "nationalQualityStrategyDomain": "ECC",
    "measureType": "process",
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    "eMeasureId": "CMS124v5",
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    "strata": [
      {
        "description": "Women with one or more screenings for cervical cancer. Appropriate screenings are defined by any one of the following criteria:\r\n\r\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\r\n \r\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": {
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        "name": "screenedForCancer"
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            "code": "G8721"
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            "code": "G8722"
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            "code": "G8723"
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        ],
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    ]
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          "S22.018B",
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          "S22.021A",
          "S22.021B",
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          "S22.022B",
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          "S22.069B",
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          "S22.070B",
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          "S22.071B",
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          "S22.072B",
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          "S22.078B",
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          "S22.079B",
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          "S22.080B",
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          "S22.081B",
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          "S22.082B",
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          "S22.088B",
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          "S22.22XA",
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          "S22.43XB",
          "S22.49XA",
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          "S22.5XXB",
          "S22.9XXA",
          "S22.9XXB",
          "S32.000A",
          "S32.000B",
          "S32.001A",
          "S32.001B",
          "S32.002A",
          "S32.002B",
          "S32.008A",
          "S32.008B",
          "S32.009A",
          "S32.009B",
          "S32.010A",
          "S32.010B",
          "S32.011A",
          "S32.011B",
          "S32.012A",
          "S32.012B",
          "S32.018A",
          "S32.018B",
          "S32.019A",
          "S32.019B",
          "S32.020A",
          "S32.020B",
          "S32.021A",
          "S32.021B",
          "S32.022A",
          "S32.022B",
          "S32.028A",
          "S32.028B",
          "S32.029A",
          "S32.029B",
          "S32.030A",
          "S32.030B",
          "S32.031A",
          "S32.031B",
          "S32.032A",
          "S32.032B",
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          "S32.038B",
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          "S32.039B",
          "S32.040A",
          "S32.040B",
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          "S32.051A",
          "S32.051B",
          "S32.052A",
          "S32.052B",
          "S32.058A",
          "S32.058B",
          "S32.059A",
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          "S32.10XA",
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          "S32.110A",
          "S32.110B",
          "S32.111A",
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          "S32.112A",
          "S32.112B",
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          "S32.119B",
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          "S32.121B",
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          "S32.122B",
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          "S32.129B",
          "S32.130A",
          "S32.130B",
          "S32.131A",
          "S32.131B",
          "S32.132A",
          "S32.132B",
          "S32.139A",
          "S32.139B",
          "S32.14XA",
          "S32.14XB",
          "S32.15XA",
          "S32.15XB",
          "S32.16XA",
          "S32.16XB",
          "S32.17XA",
          "S32.17XB",
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          "S32.2XXA",
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          "S32.301A",
          "S32.301B",
          "S32.302A",
          "S32.302B",
          "S32.309A",
          "S32.309B",
          "S32.311A",
          "S32.311B",
          "S32.312A",
          "S32.312B",
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            "code": "99231"
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            "code": "99232"
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            "code": "99233"
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            "code": "99238"
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            "code": "99239"
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            "code": "99281"
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            "code": "99282"
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            "code": "99285"
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            "code": "99291"
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            "code": "99316"
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            "code": "99318"
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            "code": "99324"
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            "code": "99325"
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            "code": "99326"
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            "code": "99327"
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            "code": "99328"
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            "code": "99337"
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            "code": "99341"
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            "code": "99342"
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            "code": "99344"
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      "cmsWebInterface": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Web-Interface-Measures/2017 WI_CARE2.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "multiPerformanceRate",
    "title": "Follow-Up After Hospitalization for Mental Illness (FUH)",
    "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 an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported:\n<br/><ul><li> The percentage of discharges for which the patient received follow-up within 30 days of discharge.\n</li><li> The percentage of discharges for which the patient received follow-up within 7 days of discharge\n\n</li></ul>",
    "nationalQualityStrategyDomain": "CCC",
    "measureType": "process",
    "measureId": "391",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0576",
    "isInverse": false,
    "strata": [
      {
        "description": "The percentage of discharges for which the patient received follow-up within 30 days of discharge",
        "name": "30days"
      },
      {
        "description": "The percentage of discharges for which the patient received follow-up within 7 days of discharge",
        "name": "overall"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "National Committee for Quality Assurance",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "mentalBehavioralHealth",
      "pediatrics"
    ],
    "overallAlgorithm": "overallStratumOnly",
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_391_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Functional Outcome Assessment",
    "description": "Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies",
    "nationalQualityStrategyDomain": "CCC",
    "measureType": "process",
    "measureId": "182",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "2624",
    "isInverse": false,
    "strata": [
      {
        "description": "Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies",
        "name": "functionalOutcome"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "Centers for Medicare & Medicaid Services",
    "submissionMethods": [
      "claims",
      "registry"
    ],
    "measureSets": [
      "physicalMedicine"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_182_Claims.pdf",
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_182_Registry.pdf"
    },
    "eligibilityOptions": [
      {
        "minAge": 18,
        "procedureCodes": [
          {
            "code": "97161"
          },
          {
            "code": "97162"
          },
          {
            "code": "97163"
          },
          {
            "code": "97164"
          },
          {
            "code": "97165"
          },
          {
            "code": "97166"
          },
          {
            "code": "97167"
          },
          {
            "code": "97168"
          },
          {
            "code": "98940"
          },
          {
            "code": "98941"
          },
          {
            "code": "98942"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      }
    ],
    "performanceOptions": [
      {
        "optionType": "performanceMet",
        "qualityCodes": [
          {
            "code": "G8539"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "optionType": "eligiblePopulationException",
        "qualityCodes": [
          {
            "code": "G8540"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "optionType": "performanceNotMet",
        "qualityCodes": [
          {
            "code": "G8541"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "optionType": "performanceMet",
        "qualityCodes": [
          {
            "code": "G8542"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "optionType": "performanceNotMet",
        "qualityCodes": [
          {
            "code": "G8543"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "optionType": "performanceMet",
        "qualityCodes": [
          {
            "code": "G8942"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "optionType": "eligiblePopulationException",
        "qualityCodes": [
          {
            "code": "G9227"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      }
    ]
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Functional Status Assessment for Total Hip Replacement",
    "description": "Percentage of patients 18 years of age and older with primary total hip arthroplasty (THA) who completed baseline and follow-up patient-reported functional status assessments",
    "nationalQualityStrategyDomain": "PCCEO",
    "measureType": "process",
    "measureId": "376",
    "eMeasureId": "CMS56v5",
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "description": "Patients with patient-reported functional status assessment results (eg, VR-12, VR-36,PROMIS-10-Global Health, PROMIS-29, HOOS) not more than 180 days prior to the primary THA procedure, and at least 60 days and not more than 180 days after THA procedure",
        "eMeasureUuids": {
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          "numeratorUuid": "7D021618-E1EE-4C2F-AD6A-F74E03D69E43",
          "denominatorExclusionUuid": "65458ECD-6573-4203-8C56-515063BAFE19"
        },
        "name": "functionalStatus"
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    ],
    "isHighPriority": true,
    "primarySteward": "Centers for Medicare & Medicaid Services",
    "submissionMethods": [
      "electronicHealthRecord",
      "registry"
    ],
    "measureSets": [
      "orthopedicSurgery"
    ],
    "eMeasureUuid": "40280381-51f0-825b-0152-227617db152e",
    "isRegistryMeasure": false,
    "measureSpecification": {
      "electronicHealthRecord": "https://qpp.cms.gov/docs/ecqm-specs/2017/EC_CMS56v5_NQFXXXX_FSA_Hip_Replacement/CMS56v5.html"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Functional Status Assessment for Total Knee Replacement",
    "description": "Percentage of patients 18 years of age and older with primary total knee arthroplasty (TKA) who completed baseline and follow-up patient-reported functional status assessments",
    "nationalQualityStrategyDomain": "PCCEO",
    "measureType": "process",
    "measureId": "375",
    "eMeasureId": "CMS66v5",
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "description": "Patients with patient-reported functional status assessment results (eg, VR-12, VR-36, PROMIS-10 Global Health, PROMIS-29, KOOS) not more than 180 days prior to the primary TKA procedure, and at least 60 days and not more than 180 days after TKA procedure",
        "eMeasureUuids": {
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          "denominatorExclusionUuid": "0E8BFC37-A4BA-4DE6-A6F3-DF4C188AB129"
        },
        "name": "functionalStatus"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "Centers for Medicare & Medicaid Services",
    "submissionMethods": [
      "electronicHealthRecord",
      "registry"
    ],
    "measureSets": [
      "orthopedicSurgery"
    ],
    "eMeasureUuid": "40280381-51f0-825b-0152-227ce2c81597",
    "isRegistryMeasure": false,
    "measureSpecification": {
      "electronicHealthRecord": "https://qpp.cms.gov/docs/ecqm-specs/2017/EC_CMS66v5_NQFXXXX_FSA_Knee_Replacement/CMS66v5.html"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Functional Status Assessments for Congestive Heart Failure",
    "description": "Percentage of patients 65 years of age and older with congestive  heart failure who completed initial and follow-up patient-reported functional status assessments",
    "nationalQualityStrategyDomain": "PCCEO",
    "measureType": "process",
    "measureId": "377",
    "eMeasureId": "CMS90v6",
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "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 within two weeks before or during the initial encounter and the follow-up encounter during the measurement year",
        "eMeasureUuids": {
          "initialPopulationUuid": "AD37C6FE-2537-4A9B-8AD9-A372E3215F76",
          "denominatorUuid": "19ECF222-71EF-4D75-9CC2-19ED201107EA",
          "numeratorUuid": "F9B4C929-8F37-48D1-953C-489C028AE725",
          "denominatorExclusionUuid": "32DBECF3-11EC-40FB-B35D-FA1BF7366492"
        },
        "name": "functionalStatus"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "Centers for Medicare & Medicaid Services",
    "submissionMethods": [
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      "registry"
    ],
    "measureSets": [],
    "eMeasureUuid": "40280381-52fc-3a32-0153-1f3f70ca0eff",
    "isRegistryMeasure": false,
    "measureSpecification": {
      "electronicHealthRecord": "https://qpp.cms.gov/docs/ecqm-specs/2017/EC_CMS90v6_NQFXXXX_FSA_Complex_Chronic_Cond/CMS90v6.html"
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  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Functional Status Change for Patients with Elbow, Wrist or Hand Impairments",
    "description": "A self-report outcome measure of functional status (FS) for patients 14 years+ with elbow, wrist or hand impairments. The change in FS assessed using FOTO (elbow, wrist and hand) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS  outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality",
    "nationalQualityStrategyDomain": "CCC",
    "measureType": "outcome",
    "measureId": "222",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0427",
    "isInverse": false,
    "strata": [
      {
        "description": "A self-report outcome measure of functional status (FS) for patients 14 years+ with elbow, wrist or hand impairments. The change in FS assessed using FOTO (elbow, wrist and hand) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality",
        "name": "armImpairment"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "Focus on Therapeutic Outcomes, Inc.",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_222_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Functional Status Change for Patients with Foot or Ankle Impairments",
    "description": "A self-report measure of change in functional status (FS) for patients 14 years+ with foot and ankle impairments. The change in functional status (FS) assessed using FOTO's (foot and ankle) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality",
    "nationalQualityStrategyDomain": "CCC",
    "measureType": "outcome",
    "measureId": "219",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0424",
    "isInverse": false,
    "strata": [
      {
        "description": "A self-report measure of change in functional status (FS) for patients 14 years+ with foot and ankle impairments. The change in functional status (FS) assessed using FOTO’s (foot and ankle) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality",
        "name": "footImpairment"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "Focus on Therapeutic Outcomes, Inc.",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_219_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Functional Status Change for Patients with General Orthopaedic Impairments",
    "description": "A self-report outcome measure of functional status (FS) for patients 14 years+ with general orthopaedic impairments (neck, cranium, mandible, thoracic spine, ribs or other general orthopaedic impairment). The change in FS assessed using FOTO (general orthopaedic) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality",
    "nationalQualityStrategyDomain": "CCC",
    "measureType": "outcome",
    "measureId": "223",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0428",
    "isInverse": false,
    "strata": [
      {
        "description": "A self-report outcome measure of functional status (FS) for patients 14 years+ with general orthopaedic impairments (neck, cranium, mandible, thoracic spine, ribs or other general orthopedic impairment). The change in FS assessed using FOTO (general orthopedic) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality",
        "name": "orthoImpairment"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "Focus on Therapeutic Outcomes, Inc.",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_223_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Functional Status Change for Patients with Hip Impairments",
    "description": "A self-report measure of change in functional status (FS) for patients 14 years+ with hip impairments. The change in functional status (FS) assessed using FOTO's (hip) PROM (patient- reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality",
    "nationalQualityStrategyDomain": "CCC",
    "measureType": "outcome",
    "measureId": "218",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0423",
    "isInverse": false,
    "strata": [
      {
        "description": "A self-report measure of change in functional status (FS) for patients 14 years+ with hip impairments. The change in functional status (FS) assessed using FOTO’s (hip) PROM (patient- reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality",
        "name": "hipImpairment"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "Focus on Therapeutic Outcomes, Inc.",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_218_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Functional Status Change for Patients with Knee Impairments",
    "description": "A self-report measure of change in functional status for patients 14 year+ with knee impairments. The change in functional status (FS) assessed using FOTO's (knee ) PROM (patient-reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality",
    "nationalQualityStrategyDomain": "CCC",
    "measureType": "outcome",
    "measureId": "217",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0422",
    "isInverse": false,
    "strata": [
      {
        "description": "A self-report measure of change in functional status for patients 14 year+ with knee impairments. The change in functional status (FS) assessed using FOTO’s (knee) PROM (patient-reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality",
        "name": "kneeImpairment"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "Focus on Therapeutic Outcomes, Inc.",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_217_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Functional Status Change for Patients with Lumbar Impairments",
    "description": "A self-report outcome measure of change in functional status for patients 14 years+ with lumbar impairments. The change in functional status (FS) assessed using FOTO (lumbar) PROM (patient reported outcome measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality",
    "nationalQualityStrategyDomain": "CCC",
    "measureType": "outcome",
    "measureId": "220",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0425",
    "isInverse": false,
    "strata": [
      {
        "description": "A self-report outcome measure of change in functional status for patients 14 years+ with lumbar impairments. The change in functional status (FS) assessed using FOTO (lumbar) PROM (patient reported outcome measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality",
        "name": "lumbarImpairment"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "Focus on Therapeutic Outcomes, Inc.",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_220_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Functional Status Change for Patients with Shoulder Impairments",
    "description": "A self-report outcome measure of change in functional status (FS) for patients 14 years+ with shoulder impairments. The change in functional status (FS) assessed using FOTO's (shoulder) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality",
    "nationalQualityStrategyDomain": "CCC",
    "measureType": "outcome",
    "measureId": "221",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0426",
    "isInverse": false,
    "strata": [
      {
        "description": "A self-report outcome measure of change in functional status (FS) for patients 14 years+ with shoulder impairments. The change in functional status (FS) assessed using FOTO’s (shoulder) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality",
        "name": "shoulderImpariment"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "Focus on Therapeutic Outcomes, Inc.",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_221_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)",
    "description": "Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "process",
    "measureId": "005",
    "eMeasureId": "CMS135v5",
    "nqfEMeasureId": "2907",
    "nqfId": "0081",
    "isInverse": false,
    "strata": [
      {
        "description": "Patients who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge",
        "name": "LVEF<40%",
        "eMeasureUuids": {
          "initialPopulationUuid": "F3000871-B8FD-4F74-8892-281C250C11EA",
          "denominatorUuid": "C1E20830-ADFE-4D88-B979-166FA0820D5C",
          "numeratorUuid": "49E476F4-E8A1-48A6-B800-A8172073DBFB",
          "denominatorExceptionUuid": "41E08783-4358-4E0D-81BE-9616A8F58319"
        }
      }
    ],
    "isHighPriority": false,
    "primarySteward": "Physician Consortium for Performance Improvement",
    "submissionMethods": [
      "electronicHealthRecord",
      "registry"
    ],
    "measureSets": [
      "internalMedicine",
      "cardiology",
      "hospitalists",
      "generalPracticeFamilyMedicine"
    ],
    "eMeasureUuid": "40280381-52fc-3a32-0153-62239c5d1ef6",
    "isRegistryMeasure": false,
    "measureSpecification": {
      "electronicHealthRecord": "https://qpp.cms.gov/docs/ecqm-specs/2017/EC_CMS135v5_NQF2907_HF_ACEARB/CMS135v5.html",
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_005_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)",
    "description": "Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "process",
    "measureId": "008",
    "eMeasureId": "CMS144v5",
    "nqfEMeasureId": "2908",
    "nqfId": "0083",
    "isInverse": false,
    "strata": [
      {
        "description": "Patients who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge",
        "name": "HF",
        "eMeasureUuids": {
          "initialPopulationUuid": "5ED1A428-A266-47E5-AE4F-DB97A65BB1D4",
          "denominatorUuid": "1E6C181E-91F6-4A61-82E0-7360C81CE3B0",
          "numeratorUuid": "ABBFFB54-E629-4520-875E-F6D18BC651B1",
          "denominatorExceptionUuid": "E9280685-6046-438D-AE45-0F7EDBA29C33"
        }
      }
    ],
    "isHighPriority": false,
    "primarySteward": "Physician Consortium for Performance Improvement",
    "submissionMethods": [
      "electronicHealthRecord",
      "registry"
    ],
    "measureSets": [
      "cardiology",
      "hospitalists",
      "generalPracticeFamilyMedicine"
    ],
    "eMeasureUuid": "40280381-52fc-3a32-0153-1a3981870b45",
    "isRegistryMeasure": false,
    "measureSpecification": {
      "electronicHealthRecord": "https://qpp.cms.gov/docs/ecqm-specs/2017/EC_CMS144v5_NQF2908_HF_BB/CMS144v5.html",
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_008_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry",
    "description": "Percentage of patients aged 18 years and older, seen within a 12 month reporting period, with a diagnosis of chronic lymphocytic leukemia (CLL) made at any time during or prior to the reporting period who had baseline flow cytometry studies performed and documented in the chart",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "process",
    "measureId": "070",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0379",
    "isInverse": false,
    "strata": [
      {
        "description": "Percentage of patients aged 18 years and older, seen within a 12 month reporting period, with a diagnosis of chronic lymphocytic leukemia (CLL) made at any time during or prior to the reporting period who had baseline flow cytometry studies performed and documented in the chart",
        "name": "CLL"
      }
    ],
    "isHighPriority": false,
    "primarySteward": "Physician Consortium for Performance Improvement",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_070_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Hematology: Multiple Myeloma: Treatment with Bisphosphonates",
    "description": "Percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12 month reporting period",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "process",
    "measureId": "069",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0380",
    "isInverse": false,
    "strata": [
      {
        "description": "Percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12 month reporting period.",
        "name": "MM"
      }
    ],
    "isHighPriority": false,
    "primarySteward": "American Society of Hematology",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_069_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow",
    "description": "Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "process",
    "measureId": "067",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0377",
    "isInverse": false,
    "strata": [
      {
        "description": "Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow",
        "name": "MDS"
      }
    ],
    "isHighPriority": false,
    "primarySteward": "American Society of Hematology",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_067_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy",
    "description": "Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy with documentation of iron stores within 60 days prior to initiating erythropoietin therapy",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "process",
    "measureId": "068",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0378",
    "isInverse": false,
    "strata": [
      {
        "description": "Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy with documentation of iron stores within 60 days prior to initiating erythropoietin therapy",
        "name": "MDS"
      }
    ],
    "isHighPriority": false,
    "primarySteward": "American Society of Hematology",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_068_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options",
    "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\n",
    "nationalQualityStrategyDomain": "PCCEO",
    "measureType": "process",
    "measureId": "390",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "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",
        "name": "hepC"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "American Gastroenterological Association",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "gastroenterology"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_390_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis",
    "description": "Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month reporting period",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "process",
    "measureId": "401",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "description": "Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month reporting period",
        "name": "hepC"
      }
    ],
    "isHighPriority": false,
    "primarySteward": "American Gastroenterological Association",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "internalMedicine",
      "gastroenterology",
      "generalPracticeFamilyMedicine"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_401_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies",
    "description": "Proportion of female patients (aged 18 years and older) with breast cancer who are human epidermal growth factor receptor 2 (HER2)/neu negative who are not administered HER2-targeted therapies",
    "nationalQualityStrategyDomain": "ECR",
    "measureType": "process",
    "measureId": "449",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "1857",
    "isInverse": false,
    "strata": [
      {
        "description": "Proportion of female patients (aged 18 years and older) with breast cancer who are human epidermal growth factor receptor 2 (HER2)/neu negative who are not administered HER2-targeted therapies",
        "name": "breastCancer"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "American Society of Clinical Oncology",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "generalOncology"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_449_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "multiPerformanceRate",
    "title": "HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis",
    "description": "Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis jiroveci pneumonia (PCP) prophylaxis",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "process",
    "measureId": "160",
    "eMeasureId": "CMS52v5",
    "nqfEMeasureId": null,
    "nqfId": "0405",
    "isInverse": false,
    "strata": [
      {
        "description": "Patients who were prescribed Pneumocystis jiroveci pneumonia (PCP) prophylaxis within 3 months of CD4 count below 200 cells/mm3",
        "eMeasureUuids": {
          "initialPopulationUuid": "E681DBF8-F827-4586-B3E0-178FF19EC3A2",
          "denominatorUuid": "04BF53CE-6993-4EA2-BFE5-66E36172B388",
          "numeratorUuid": "631C0B49-83F4-4A54-96C4-7E0766B2407C",
          "denominatorExceptionUuid": "58347456-D1F3-4BBB-9B35-5D42825A0AB3"
        },
        "name": "CD4<200/mm3"
      },
      {
        "description": "Patients who were prescribed Pneumocystis jiroveci pneumonia (PCP) prophylaxis within 3 months of CD4 count below 500 cells/mm3 or a CD4 percentage below 15%",
        "eMeasureUuids": {
          "initialPopulationUuid": "AAC578DB-1900-43BD-BBBF-50014A5457E5",
          "denominatorUuid": "1574973E-EB52-40C7-9709-25ABEDBA99A3",
          "numeratorUuid": "5B7AC4EC-547A-47E5-AC5E-618401175511",
          "denominatorExceptionUuid": "B7CCA1A6-F352-4A23-BC89-6FE9B60DC0C6"
        },
        "name": "CD4<500/mm3OrCD4<15%"
      },
      {
        "description": "Patients who were prescribed Pneumocystis jiroveci pneumonia (PCP) prophylaxis at the time of diagnosis of HIV",
        "eMeasureUuids": {
          "initialPopulationUuid": "AF36C4A9-8BD9-4E21-838D-A47A1845EB90",
          "denominatorUuid": "B95BC0D3-572E-462B-BAA2-46CD33A865CD",
          "numeratorUuid": "86F74F07-D593-44F6-AA12-405966400963"
        },
        "name": "atDiagnosis"
      }
    ],
    "isHighPriority": false,
    "primarySteward": "National Committee for Quality Assurance",
    "submissionMethods": [
      "electronicHealthRecord",
      "registry"
    ],
    "measureSets": [
      "allergyImmunology",
      "pediatrics"
    ],
    "eMeasureUuid": "40280381-51f0-825b-0152-2273af5a150b",
    "overallAlgorithm": "weightedAverage",
    "isRegistryMeasure": false,
    "measureSpecification": {
      "electronicHealthRecord": "https://qpp.cms.gov/docs/ecqm-specs/2017/EC_CMS52v5_NQF0405_HIVAIDS_PCP_Prophylaxis/CMS52v5.html"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis",
    "description": "Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea, and syphilis screenings were performed at least once since the diagnosis of HIV infection",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "process",
    "measureId": "205",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0409",
    "isInverse": false,
    "strata": [
      {
        "description": "Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea, and syphilis screenings were performed at least once since the diagnosis of HIV infection",
        "name": "HIV/AIDS"
      }
    ],
    "isHighPriority": false,
    "primarySteward": "National Committee for Quality Assurance",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "pediatrics"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_205_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "HIV Medical Visit Frequency",
    "description": "Percentage of patients, regardless of age with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits",
    "nationalQualityStrategyDomain": "ECR",
    "measureType": "process",
    "measureId": "340",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "2079",
    "isInverse": false,
    "strata": [
      {
        "description": "Percentage of patients, regardless of age with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits",
        "name": "HIV"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "Health Resources and Services Administration",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_340_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "HIV Viral Load Suppression",
    "description": "The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "outcome",
    "measureId": "338",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "2082",
    "isInverse": false,
    "strata": [
      {
        "description": "The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year",
        "name": "HIV"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "Health Resources and Services Administration",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "generalPracticeFamilyMedicine"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_338_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "multiPerformanceRate",
    "title": "HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation",
    "description": "Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation This measure is reported as four rates stratified by age and gender:\n<br/><ul><li> Reporting Age Criteria 1: Females 18-64years of age\n</li><li> Reporting Age Criteria 2: Males 18-64 years of age\n</li><li> Reporting Age Criteria 3: Females 65 years of age and older\n</li><li> Reporting Age Criteria 4: Males 65 years of age and older\n</li></ul>",
    "nationalQualityStrategyDomain": "PS",
    "measureType": "outcome",
    "measureId": "392",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "2474",
    "isInverse": true,
    "strata": [
      {
        "description": "Females 18-64 years of age",
        "name": "18-64F"
      },
      {
        "description": "Males 18-64 years of age",
        "name": "18-64M"
      },
      {
        "description": "Females 65 years of age and older",
        "name": "65+F"
      },
      {
        "description": "Males 65 years of age and older",
        "name": "65+M"
      },
      {
        "description": "Overall percentage of patients with cardiac tamponade and/or pericardiocentesis occurring within 30 days Eligible clinicians should continue to report the measure as specified, with no additional steps needed to account for multiple performance rates.",
        "name": "overall"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "The Heart Rhythm Society",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "electrophysiologyCardiacSpecialist"
    ],
    "overallAlgorithm": "overallStratumOnly",
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_392_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "multiPerformanceRate",
    "title": "HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate",
    "description": "Patients with physician-specific risk-standardized rates of procedural complications following the first time implantation of an ICD",
    "nationalQualityStrategyDomain": "PS",
    "measureType": "outcome",
    "measureId": "348",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": true,
    "strata": [
      {
        "description": "Patients with first time implants with one or more complications or mortality within 30 days",
        "name": "30"
      },
      {
        "description": "Patients with first time implants with one or more complications within 90 days",
        "name": "90"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "The Heart Rhythm Society",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "electrophysiologyCardiacSpecialist"
    ],
    "overallAlgorithm": "weightedAverage",
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_348_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision",
    "description": "Infection rate following CIED device implantation, replacement, or revision\n",
    "nationalQualityStrategyDomain": "PS",
    "measureType": "outcome",
    "measureId": "393",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": true,
    "strata": [
      {
        "description": "Infection rate following CIED device implantation, replacement, or revision",
        "name": "CIED"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "The Heart Rhythm Society",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "electrophysiologyCardiacSpecialist"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_393_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Hypertension: Improvement in Blood Pressure",
    "description": "Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period.",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "intermediateOutcome",
    "measureId": "373",
    "eMeasureId": "CMS65v6",
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "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": "78CD5ACE-054C-43DF-A743-5F1E5BA4C099",
          "denominatorUuid": "CE973C7A-B867-422B-8408-83538E236039",
          "numeratorUuid": "F67DCC8F-4F0F-491B-957F-B21E721B040B",
          "denominatorExclusionUuid": "74F900B9-65DA-4E6C-BB2D-592189ABDDE5"
        },
        "name": "lowerFollowupBP"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "Centers for Medicare & Medicaid Services",
    "submissionMethods": [
      "electronicHealthRecord",
      "registry"
    ],
    "measureSets": [],
    "eMeasureUuid": "40280381-51f0-825b-0152-227c2f851589",
    "isRegistryMeasure": false,
    "measureSpecification": {
      "electronicHealthRecord": "https://qpp.cms.gov/docs/ecqm-specs/2017/EC_CMS65v6_NQFXXXX_Hypertension_BP_Improve/CMS65v6.html"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Image Confirmation of Successful Excision of Image-Localized Breast Lesion",
    "description": "Image confirmation of lesion(s) targeted for image guided excisional biopsy or image guided partial mastectomy in patients with nonpalpable, image-detected breast lesion(s). 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": "PS",
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        "description": "Image confirmation of lesion(s) targeted for image guided excisional biopsy or image guided partial mastectomy in patients with nonpalpable, image-detected breast lesion(s). 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",
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    "isHighPriority": true,
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    "measureSpecification": {
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    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "multiPerformanceRate",
    "title": "Immunizations for Adolescents",
    "description": "The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday",
    "nationalQualityStrategyDomain": "CPH",
    "measureType": "process",
    "measureId": "394",
    "eMeasureId": null,
    "nqfEMeasureId": null,
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    "isInverse": false,
    "strata": [
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      {
        "description": "Patients who had one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) on or between the patient’s 10th and 13th birthdays",
        "name": "Tdap"
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      {
        "description": "Patients who had at least three HPV vaccines with different dates of service on or between the patient’s 9th and 13th birthdays",
        "name": "HPV"
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      {
        "description": "All patients who are compliant for Meningococcal, Tdap and HPV during the specified timeframes.",
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    "primarySteward": "National Committee for Quality Assurance",
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    ],
    "measureSets": [
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    ],
    "overallAlgorithm": "overallStratumOnly",
    "isRegistryMeasure": false,
    "measureSpecification": {
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    }
  },
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    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy",
    "description": "Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted within one year prior to receiving a first course of anti-TNF (tumor necrosis factor) therapy",
    "nationalQualityStrategyDomain": "ECC",
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    "measureId": "275",
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    "strata": [
      {
        "description": "Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted within one year prior to receiving a first course of anti-TNF (tumor necrosis factor) therapy",
        "name": "IBD"
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    ],
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    "primarySteward": "American Gastroenterological Association",
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    "measureSets": [
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    "isRegistryMeasure": false,
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    "category": "quality",
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    "metricType": "singlePerformanceRate",
    "title": "Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury - Bone Loss Assessment",
    "description": "Percentage of patients aged 18 years and older 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",
    "nationalQualityStrategyDomain": "ECC",
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    "strata": [
      {
        "description": "Percentage of patients aged 18 years and older 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",
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    ],
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    "lastPerformanceYear": null,
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    "title": "Initiation and Engagement of Alcohol and Other Drug Dependence Treatment",
    "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.\na. Percentage of patients who initiated treatment within 14 days of the diagnosis.\nb. 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.\n",
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    "nationalQualityStrategyDomain": "ECC",
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        "name": "IVDAllOrNone"
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    "description": "Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period.",
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          "I70.91",
          "I70.92",
          "I74.01",
          "I74.09",
          "I74.10",
          "I74.11",
          "I74.19",
          "I74.2",
          "I74.3",
          "I74.4",
          "I74.5",
          "I74.8",
          "I74.9",
          "I75.011",
          "I75.012",
          "I75.013",
          "I75.019",
          "I75.021",
          "I75.022",
          "I75.023",
          "I75.029",
          "I75.81",
          "I75.89"
        ],
        "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"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "diagnosisCodes": [
          "I21.01",
          "I21.02",
          "I21.09",
          "I21.11",
          "I21.19",
          "I21.21",
          "I21.29",
          "I21.3",
          "I21.4"
        ],
        "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"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "minAge": 18,
        "procedureCodes": [
          {
            "code": "33510"
          },
          {
            "code": "33511"
          },
          {
            "code": "33512"
          },
          {
            "code": "33513"
          },
          {
            "code": "33514"
          },
          {
            "code": "33516"
          },
          {
            "code": "33517"
          },
          {
            "code": "33518"
          },
          {
            "code": "33519"
          },
          {
            "code": "33521"
          },
          {
            "code": "33522"
          },
          {
            "code": "33523"
          },
          {
            "code": "33533"
          },
          {
            "code": "33534"
          },
          {
            "code": "33535"
          },
          {
            "code": "33536"
          },
          {
            "code": "92920"
          },
          {
            "code": "92924"
          },
          {
            "code": "92928"
          },
          {
            "code": "92933"
          },
          {
            "code": "92937"
          },
          {
            "code": "92941"
          },
          {
            "code": "92943"
          },
          {
            "code": "S2205"
          },
          {
            "code": "S2206"
          },
          {
            "code": "S2207"
          },
          {
            "code": "S2208"
          },
          {
            "code": "S2209"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      }
    ],
    "performanceOptions": [
      {
        "optionType": "eligiblePopulationExclusion",
        "qualityCodes": [
          {
            "code": "G9723"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "optionType": "eligiblePopulationExclusion",
        "qualityCodes": [
          {
            "code": "G9724"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "optionType": "performanceMet",
        "qualityCodes": [
          {
            "code": "G8598"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "optionType": "performanceNotMet",
        "qualityCodes": [
          {
            "code": "G8599"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      }
    ]
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "KRAS Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy",
    "description": "Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom KRAS gene mutation testing was performed",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "process",
    "measureId": "451",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "1859",
    "isInverse": false,
    "strata": [
      {
        "description": "Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom KRAS gene mutation testing was performed",
        "name": "KRASGeneMutation"
      }
    ],
    "isHighPriority": false,
    "primarySteward": "American Society of Clinical Oncology",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "generalOncology"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_451_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Lung Cancer Reporting (Biopsy/Cytology Specimens)",
    "description": "Pathology reports based on biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type or classified as NSCLC-NOS with an explanation included in the pathology report",
    "nationalQualityStrategyDomain": "CCC",
    "measureType": "outcome",
    "measureId": "395",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "description": "Pathology reports based on biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type or classified as NSCLC-NOS with an explanation included in the pathology report",
        "name": "lungCancer"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "College of American Pathologists",
    "submissionMethods": [
      "claims",
      "registry"
    ],
    "measureSets": [
      "pathology"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_395_Claims.pdf",
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_395_Registry.pdf"
    },
    "eligibilityOptions": [
      {
        "diagnosisCodes": [
          "C34.00",
          "C34.01",
          "C34.02",
          "C34.10",
          "C34.11",
          "C34.12",
          "C34.2",
          "C34.30",
          "C34.31",
          "C34.32",
          "C34.80",
          "C34.81",
          "C34.82",
          "C34.90",
          "C34.91",
          "C34.92"
        ],
        "minAge": 18,
        "procedureCodes": [
          {
            "code": "88104"
          },
          {
            "code": "88108"
          },
          {
            "code": "88112"
          },
          {
            "code": "88173"
          },
          {
            "code": "88305"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      }
    ],
    "performanceOptions": [
      {
        "optionType": "performanceMet",
        "qualityCodes": [
          {
            "code": "G9418"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "optionType": "eligiblePopulationException",
        "qualityCodes": [
          {
            "code": "G9419"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "optionType": "eligiblePopulationExclusion",
        "qualityCodes": [
          {
            "code": "G9420"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "optionType": "performanceNotMet",
        "qualityCodes": [
          {
            "code": "G9421"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      }
    ]
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Lung Cancer Reporting (Resection Specimens)",
    "description": "Pathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer, histologic type",
    "nationalQualityStrategyDomain": "CCC",
    "measureType": "outcome",
    "measureId": "396",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "description": "Pathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer, histologic type",
        "name": "lungCarcinoma"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "College of American Pathologists",
    "submissionMethods": [
      "claims",
      "registry"
    ],
    "measureSets": [
      "pathology"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_396_Claims.pdf",
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_396_Registry.pdf"
    },
    "eligibilityOptions": [
      {
        "diagnosisCodes": [
          "C34.00",
          "C34.01",
          "C34.02",
          "C34.10",
          "C34.11",
          "C34.12",
          "C34.2",
          "C34.30",
          "C34.31",
          "C34.32",
          "C34.80",
          "C34.81",
          "C34.82",
          "C34.90",
          "C34.91",
          "C34.92"
        ],
        "minAge": 18,
        "procedureCodes": [
          {
            "code": "88309"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      }
    ],
    "performanceOptions": [
      {
        "optionType": "performanceMet",
        "qualityCodes": [
          {
            "code": "G9422"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "optionType": "eligiblePopulationException",
        "qualityCodes": [
          {
            "code": "G9423"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "optionType": "eligiblePopulationExclusion",
        "qualityCodes": [
          {
            "code": "G9424"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "optionType": "performanceNotMet",
        "qualityCodes": [
          {
            "code": "G9425"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      }
    ]
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Maternal Depression Screening",
    "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.\n",
    "nationalQualityStrategyDomain": "CPH",
    "measureType": "process",
    "measureId": "372",
    "eMeasureId": "CMS82v4",
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "description": "Children with documentation of maternal screening or treatment for postpartum depression for the mother.",
        "eMeasureUuids": {
          "initialPopulationUuid": "D3ADB281-2F53-4BE6-89A9-124480DE787D",
          "denominatorUuid": "6B845134-C1B7-4383-AFB3-1FFB7EAD359B",
          "numeratorUuid": "D2A5FF72-DE5E-413A-829E-C763FC07DF4A"
        },
        "name": "screeningOrTreatment"
      }
    ],
    "isHighPriority": false,
    "primarySteward": "National Committee for Quality Assurance",
    "submissionMethods": [
      "electronicHealthRecord",
      "registry"
    ],
    "measureSets": [],
    "eMeasureUuid": "40280381-51f0-825b-0152-2295c55c16aa",
    "isRegistryMeasure": false,
    "measureSpecification": {
      "electronicHealthRecord": "https://qpp.cms.gov/docs/ecqm-specs/2017/EC_CMS82v4_NQFXXXX_Maternal_Dep_Screening/CMS82v4.html"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Maternity Care: Elective Delivery or Early Induction Without Medical Indication at >= 37 and < 39 Weeks (Overuse)",
    "description": "Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at\n>= 37 and < 39 weeks of gestation completed who had elective deliveries or early inductions without medical indication\n",
    "nationalQualityStrategyDomain": "PS",
    "measureType": "outcome",
    "measureId": "335",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "description": "Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at ≥ 37 and < 39 weeks of gestation completed who had elective deliveries or early inductions without medical indication",
        "name": "birth"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "Centers for Medicare & Medicaid Services",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_335_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Maternity Care: Post-Partum Follow-Up and Care Coordination",
    "description": "Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for post-partum care within 8 weeks of giving birth who received a breast feeding evaluation and education, post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and family and contraceptive planning",
    "nationalQualityStrategyDomain": "CCC",
    "measureType": "process",
    "measureId": "336",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "description": "Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for post-partum care within 8 weeks of giving birth who received a breast feeding evaluation and education, post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and family and contraceptive planning",
        "name": "postPartum"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "Centers for Medicare & Medicaid Services",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_336_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Medication Management for People with Asthma",
    "description": "The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period",
    "nationalQualityStrategyDomain": "ECR",
    "measureType": "process",
    "measureId": "444",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "1799",
    "isInverse": false,
    "strata": [
      {
        "description": "The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period",
        "name": "asthma"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "National Committee for Quality Assurance",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "allergyImmunology",
      "generalPracticeFamilyMedicine",
      "pediatrics"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_444_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "multiPerformanceRate",
    "title": "Medication Reconciliation Post-Discharge",
    "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.\nThis measure is reported as three rates stratified by age group:\n<br/><ul><li> Reporting Criteria 1: 18-64 years of age\n</li><li> Reporting Criteria 2: 65 years and older\n</li><li> Total Rate: All patients 18 years of age and older\n</li></ul>",
    "nationalQualityStrategyDomain": "CCC",
    "measureType": "process",
    "measureId": "046",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0097",
    "isInverse": false,
    "strata": [
      {
        "description": "Performance Rate 1: Percentage of discharges from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) for patients 18-64 years 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",
        "name": "18-64"
      },
      {
        "description": "Performance Rate 2: Percentage of discharges from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) for patients 65 years and older 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",
        "name": "65+"
      },
      {
        "description": "Total Rate (Overall Performance Rate): Percentage of discharges from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older 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",
        "name": "overall"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "National Committee for Quality Assurance",
    "submissionMethods": [
      "claims",
      "cmsWebInterface",
      "registry"
    ],
    "measureSets": [],
    "overallAlgorithm": "overallStratumOnly",
    "isRegistryMeasure": false,
    "measureSpecification": {
      "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_046_Claims.pdf",
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_046_Registry.pdf"
    },
    "eligibilityOptions": [
      {
        "maxAge": 64,
        "minAge": 18,
        "procedureCodes": [
          {
            "code": "90791"
          },
          {
            "code": "90792"
          },
          {
            "code": "90832"
          },
          {
            "code": "90834"
          },
          {
            "code": "90837"
          },
          {
            "code": "90839"
          },
          {
            "code": "90845"
          },
          {
            "code": "99201"
          },
          {
            "code": "99202"
          },
          {
            "code": "99203"
          },
          {
            "code": "99204"
          },
          {
            "code": "99205"
          },
          {
            "code": "99211"
          },
          {
            "code": "99212"
          },
          {
            "code": "99213"
          },
          {
            "code": "99214"
          },
          {
            "code": "99215"
          },
          {
            "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": "99495"
          },
          {
            "code": "99496"
          },
          {
            "code": "G0402"
          },
          {
            "code": "G0438"
          },
          {
            "code": "G0439"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "minAge": 65,
        "procedureCodes": [
          {
            "code": "90791"
          },
          {
            "code": "90792"
          },
          {
            "code": "90832"
          },
          {
            "code": "90834"
          },
          {
            "code": "90837"
          },
          {
            "code": "90839"
          },
          {
            "code": "90845"
          },
          {
            "code": "99201"
          },
          {
            "code": "99202"
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            "code": "99327"
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            "code": "99328"
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            "code": "99334"
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            "code": "99335"
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            "code": "99336"
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            "code": "99337"
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            "code": "99341"
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            "code": "99342"
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            "code": "99348"
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            "code": "90845"
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            "code": "99201"
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            "code": "99203"
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            "code": "99204"
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            "code": "99205"
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            "code": "99211"
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            "code": "99213"
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            "code": "99326"
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        "submissionMethods": [
          "claims"
        ]
      }
    ],
    "performanceOptions": [
      {
        "optionType": "performanceMet",
        "qualityCodes": [
          {
            "code": "0520F",
            "modifierExclusions": [
              "1P",
              "2P",
              "3P",
              "8P"
            ]
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "optionType": "performanceNotMet",
        "qualityCodes": [
          {
            "code": "0520F",
            "modifierExclusions": [
              "1P",
              "2P",
              "3P"
            ],
            "modifiers": [
              "8P"
            ]
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      }
    ]
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk",
    "description": "Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infection",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "process",
    "measureId": "400",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "description": "Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infection",
        "name": "HCV"
      }
    ],
    "isHighPriority": false,
    "primarySteward": "Physician Consortium for Performance Improvement",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "internalMedicine",
      "generalPracticeFamilyMedicine"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_400_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Operative Mortality Stratified by the Five STS-EACTS Mortality Categories",
    "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 acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool",
    "nationalQualityStrategyDomain": "PS",
    "measureType": "outcome",
    "measureId": "446",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0733",
    "isInverse": true,
    "strata": [
      {
        "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 acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool",
        "name": "heartSurgery"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "Society of Thoracic Surgeons",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_446_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Opioid Therapy Follow-up Evaluation",
    "description": "All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "process",
    "measureId": "408",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "description": "All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record",
        "name": "opiates"
      }
    ],
    "isHighPriority": false,
    "primarySteward": "American Academy of Neurology",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "internalMedicine",
      "neurology",
      "physicalMedicine",
      "generalPracticeFamilyMedicine"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_408_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "multiPerformanceRate",
    "title": "Optimal Asthma Control",
    "description": "Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbation",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "outcome",
    "measureId": "398",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "description": "Overall Percentage for patients (aged 5-50 years) with well-controlled asthma, without elevated risk of exacerbation.",
        "name": "overall"
      },
      {
        "description": "Percentage of pediatric patients (aged 5-17 years) with well-controlled asthma, without elevated risk of exacerbation.",
        "name": "5-17"
      },
      {
        "description": "Percentage of adult patients (aged 18-50 years) with well-controlled asthma, without elevated risk of exacerbation.",
        "name": "18-50"
      },
      {
        "description": "Asthma well-controlled (take the most recent ACT) for patients 5 to 17 with Asthma",
        "name": "ACT5-17"
      },
      {
        "description": "Asthma well-controlled (take the most recent ACT) for patients 18 to 50 with Asthma",
        "name": "ACT18-50"
      },
      {
        "description": "Patient not at elevated risk of exacerbation for patients 5 to 17 with Asthma",
        "name": "lowRisk5-17"
      },
      {
        "description": "Patient not at elevated risk of exacerbation for patients 18 to 50 with Asthma",
        "name": "lowRisk18-50"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "Minnesota Community Measurement",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "allergyImmunology",
      "generalPracticeFamilyMedicine"
    ],
    "overallAlgorithm": "overallStratumOnly",
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_398_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines",
    "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": "CCC",
    "measureType": "process",
    "measureId": "364",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "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 patient risk factors",
        "name": "CT"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "American College of Radiology",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "diagnosticRadiology"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_364_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes",
    "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": "CCC",
    "measureType": "structure",
    "measureId": "362",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "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",
        "name": "CT"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "American College of Radiology",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "diagnosticRadiology"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_362_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies",
    "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": "PS",
    "measureType": "process",
    "measureId": "360",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "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",
        "name": "CT"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "American College of Radiology",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "diagnosticRadiology"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_360_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry",
    "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": "PS",
    "measureType": "structure",
    "measureId": "361",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "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",
        "name": "CT"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "American College of Radiology",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "diagnosticRadiology"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_361_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive",
    "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": "CCC",
    "measureType": "structure",
    "measureId": "363",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "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",
        "name": "CT"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "American College of Radiology",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "diagnosticRadiology"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_363_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description",
    "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": "CCC",
    "measureType": "process",
    "measureId": "359",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "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",
        "name": "CT"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "American College of Radiology",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "diagnosticRadiology"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_359_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Osteoarthritis (OA): Function and Pain Assessment",
    "description": "Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain",
    "nationalQualityStrategyDomain": "PCCEO",
    "measureType": "process",
    "measureId": "109",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "description": "Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain",
        "name": "OA"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "American Academy of Orthopedic Surgeons",
    "submissionMethods": [
      "claims",
      "registry"
    ],
    "measureSets": [
      "internalMedicine",
      "orthopedicSurgery",
      "physicalMedicine",
      "preventiveMedicine",
      "generalPracticeFamilyMedicine"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_109_Claims.pdf",
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_109_Registry.pdf"
    },
    "eligibilityOptions": [
      {
        "diagnosisCodes": [
          "M15.0",
          "M15.1",
          "M15.2",
          "M15.3",
          "M15.4",
          "M15.8",
          "M15.9",
          "M16.0",
          "M16.10",
          "M16.11",
          "M16.12",
          "M16.2",
          "M16.30",
          "M16.31",
          "M16.32",
          "M16.4",
          "M16.50",
          "M16.51",
          "M16.52",
          "M16.6",
          "M16.7",
          "M16.9",
          "M17.0",
          "M17.10",
          "M17.11",
          "M17.12",
          "M17.2",
          "M17.30",
          "M17.31",
          "M17.32",
          "M17.4",
          "M17.5",
          "M17.9",
          "M18.0",
          "M18.10",
          "M18.11",
          "M18.12",
          "M18.2",
          "M18.30",
          "M18.31",
          "M18.32",
          "M18.4",
          "M18.50",
          "M18.51",
          "M18.52",
          "M18.9",
          "M19.011",
          "M19.012",
          "M19.019",
          "M19.021",
          "M19.022",
          "M19.029",
          "M19.031",
          "M19.032",
          "M19.039",
          "M19.041",
          "M19.042",
          "M19.049",
          "M19.071",
          "M19.072",
          "M19.079",
          "M19.111",
          "M19.112",
          "M19.119",
          "M19.121",
          "M19.122",
          "M19.129",
          "M19.131",
          "M19.132",
          "M19.139",
          "M19.141",
          "M19.142",
          "M19.149",
          "M19.171",
          "M19.172",
          "M19.179",
          "M19.211",
          "M19.212",
          "M19.219",
          "M19.221",
          "M19.222",
          "M19.229",
          "M19.231",
          "M19.232",
          "M19.239",
          "M19.241",
          "M19.242",
          "M19.249",
          "M19.271",
          "M19.272",
          "M19.279",
          "M19.90",
          "M19.91",
          "M19.92",
          "M19.93"
        ],
        "minAge": 21,
        "procedureCodes": [
          {
            "code": "99201"
          },
          {
            "code": "99202"
          },
          {
            "code": "99203"
          },
          {
            "code": "99204"
          },
          {
            "code": "99205"
          },
          {
            "code": "99212"
          },
          {
            "code": "99213"
          },
          {
            "code": "99214"
          },
          {
            "code": "99215"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      }
    ],
    "performanceOptions": [
      {
        "optionType": "performanceMet",
        "qualityCodes": [
          {
            "code": "1006F",
            "modifierExclusions": [
              "1P",
              "2P",
              "3P",
              "8P"
            ]
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "optionType": "performanceNotMet",
        "qualityCodes": [
          {
            "code": "1006F",
            "modifierExclusions": [
              "1P",
              "2P",
              "3P"
            ],
            "modifiers": [
              "8P"
            ]
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      }
    ]
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Osteoporosis Management in Women Who Had a Fracture",
    "description": "The percentage of women age 50-85 who suffered a fracture and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "process",
    "measureId": "418",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0053",
    "isInverse": false,
    "strata": [
      {
        "description": "The percentage of women age 50-85 who suffered a fracture and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture",
        "name": "osteoporosis"
      }
    ],
    "isHighPriority": false,
    "primarySteward": "National Committee for Quality Assurance",
    "submissionMethods": [
      "claims",
      "registry"
    ],
    "measureSets": [
      "internalMedicine",
      "obstetricsGynecology",
      "generalPracticeFamilyMedicine"
    ],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_418_Claims.pdf",
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_418_Registry.pdf"
    },
    "eligibilityOptions": [
      {
        "diagnosisCodes": [
          "M48.40XA",
          "M48.41XA",
          "M48.42XA",
          "M48.43XA",
          "M48.44XA",
          "M48.45XA",
          "M48.46XA",
          "M48.47XA",
          "M48.48XA",
          "M84.311A",
          "M84.312A",
          "M84.319A",
          "M84.321A",
          "M84.322A",
          "M84.329A",
          "M84.331A",
          "M84.332A",
          "M84.333A",
          "M84.334A",
          "M84.339A",
          "M84.341A",
          "M84.342A",
          "M84.343A",
          "M84.350A",
          "M84.351A",
          "M84.352A",
          "M84.353A",
          "M84.359A",
          "M84.361A",
          "M84.362A",
          "M84.363A",
          "M84.364A",
          "M84.369A",
          "M84.371A",
          "M84.372A",
          "M84.373A",
          "M84.374A",
          "M84.375A",
          "M84.376A",
          "M84.38XA",
          "M84.750A",
          "M84.751A",
          "M84.752A",
          "M84.753A",
          "M84.754A",
          "M84.755A",
          "M84.756A",
          "M84.757A",
          "M84.759A",
          "S12.000A",
          "S12.000B",
          "S12.001A",
          "S12.001B",
          "S12.01XA",
          "S12.01XB",
          "S12.02XA",
          "S12.02XB",
          "S12.030A",
          "S12.030B",
          "S12.031A",
          "S12.031B",
          "S12.040A",
          "S12.040B",
          "S12.041A",
          "S12.041B",
          "S12.090A",
          "S12.090B",
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          },
          {
            "code": "43325"
          },
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            "code": "43327"
          },
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            "code": "43328"
          },
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            "code": "43330"
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            "code": "43331"
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            "code": "43332"
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            "code": "43333"
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            "code": "43334"
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            "code": "43335"
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            "code": "43336"
          },
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            "code": "43337"
          },
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            "code": "43340"
          },
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            "code": "43341"
          },
          {
            "code": "43351"
          },
          {
            "code": "43352"
          },
          {
            "code": "43360"
          },
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            "code": "43361"
          },
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            "code": "43400"
          },
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            "code": "43401"
          },
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            "code": "43405"
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            "code": "43410"
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            "code": "43415"
          },
          {
            "code": "43420"
          },
          {
            "code": "43425"
          },
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            "code": "43496"
          },
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            "code": "43500"
          },
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            "code": "43501"
          },
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            "code": "43502"
          },
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            "code": "43510"
          },
          {
            "code": "43520"
          },
          {
            "code": "43605"
          },
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            "code": "43610"
          },
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            "code": "43611"
          },
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            "code": "43620"
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            "code": "43621"
          },
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            "code": "43622"
          },
          {
            "code": "43631"
          },
          {
            "code": "43632"
          },
          {
            "code": "43633"
          },
          {
            "code": "43634"
          },
          {
            "code": "43640"
          },
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            "code": "43641"
          },
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            "code": "43644"
          },
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            "code": "43645"
          },
          {
            "code": "43651"
          },
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            "code": "43652"
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          },
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          },
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            "code": "43775"
          },
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            "code": "43800"
          },
          {
            "code": "43810"
          },
          {
            "code": "43820"
          },
          {
            "code": "43825"
          },
          {
            "code": "43830"
          },
          {
            "code": "43832"
          },
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            "code": "43840"
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            "code": "43843"
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            "code": "43845"
          },
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            "code": "43846"
          },
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            "code": "43847"
          },
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            "code": "43848"
          },
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            "code": "43850"
          },
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            "code": "43855"
          },
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          },
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            "code": "44021"
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            "code": "44100"
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          },
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          },
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            "code": "44158"
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          },
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            "code": "44180"
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            "code": "44208"
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            "code": "44210"
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            "code": "44211"
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            "code": "44212"
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            "code": "44227"
          },
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            "code": "44300"
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            "code": "44310"
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            "code": "44312"
          },
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            "code": "44314"
          },
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            "code": "44316"
          },
          {
            "code": "44320"
          },
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            "code": "44322"
          },
          {
            "code": "44340"
          },
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            "code": "44345"
          },
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            "code": "44346"
          },
          {
            "code": "44602"
          },
          {
            "code": "44603"
          },
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            "code": "44604"
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          {
            "code": "44605"
          },
          {
            "code": "44615"
          },
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            "code": "44620"
          },
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            "code": "44625"
          },
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            "code": "44626"
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            "code": "44640"
          },
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            "code": "44660"
          },
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            "code": "44661"
          },
          {
            "code": "44680"
          },
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            "code": "44700"
          },
          {
            "code": "44800"
          },
          {
            "code": "44820"
          },
          {
            "code": "44850"
          },
          {
            "code": "44900"
          },
          {
            "code": "44950"
          },
          {
            "code": "44955"
          },
          {
            "code": "44960"
          },
          {
            "code": "44970"
          },
          {
            "code": "45000"
          },
          {
            "code": "45020"
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          {
            "code": "45110"
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          {
            "code": "45111"
          },
          {
            "code": "45112"
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            "code": "45113"
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          {
            "code": "45114"
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          {
            "code": "45116"
          },
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            "code": "45119"
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          {
            "code": "45120"
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            "code": "45123"
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          {
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          },
          {
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            "code": "45135"
          },
          {
            "code": "45136"
          },
          {
            "code": "45150"
          },
          {
            "code": "45160"
          },
          {
            "code": "45171"
          },
          {
            "code": "45172"
          },
          {
            "code": "45395"
          },
          {
            "code": "45397"
          },
          {
            "code": "45400"
          },
          {
            "code": "45402"
          },
          {
            "code": "45540"
          },
          {
            "code": "45541"
          },
          {
            "code": "45550"
          },
          {
            "code": "45560"
          },
          {
            "code": "45562"
          },
          {
            "code": "45563"
          },
          {
            "code": "45800"
          },
          {
            "code": "45805"
          },
          {
            "code": "45820"
          },
          {
            "code": "45825"
          },
          {
            "code": "47100"
          },
          {
            "code": "47120"
          },
          {
            "code": "47122"
          },
          {
            "code": "47125"
          },
          {
            "code": "47130"
          },
          {
            "code": "47140"
          },
          {
            "code": "47141"
          },
          {
            "code": "47142"
          },
          {
            "code": "47350"
          },
          {
            "code": "47370"
          },
          {
            "code": "47371"
          },
          {
            "code": "47380"
          },
          {
            "code": "47381"
          },
          {
            "code": "47400"
          },
          {
            "code": "47420"
          },
          {
            "code": "47425"
          },
          {
            "code": "47460"
          },
          {
            "code": "47480"
          },
          {
            "code": "47562"
          },
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            "code": "47563"
          },
          {
            "code": "47564"
          },
          {
            "code": "47570"
          },
          {
            "code": "47600"
          },
          {
            "code": "47605"
          },
          {
            "code": "47610"
          },
          {
            "code": "47612"
          },
          {
            "code": "47620"
          },
          {
            "code": "47700"
          },
          {
            "code": "47701"
          },
          {
            "code": "47711"
          },
          {
            "code": "47712"
          },
          {
            "code": "47715"
          },
          {
            "code": "47720"
          },
          {
            "code": "47721"
          },
          {
            "code": "47740"
          },
          {
            "code": "47741"
          },
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            "code": "47760"
          },
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            "code": "47765"
          },
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            "code": "47780"
          },
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            "code": "47785"
          },
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            "code": "47800"
          },
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            "code": "47801"
          },
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            "code": "47802"
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          {
            "code": "47900"
          },
          {
            "code": "48000"
          },
          {
            "code": "48001"
          },
          {
            "code": "48020"
          },
          {
            "code": "48100"
          },
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            "code": "48102"
          },
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            "code": "48105"
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            "code": "48120"
          },
          {
            "code": "48140"
          },
          {
            "code": "48145"
          },
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            "code": "48146"
          },
          {
            "code": "48148"
          },
          {
            "code": "48150"
          },
          {
            "code": "48152"
          },
          {
            "code": "48153"
          },
          {
            "code": "48154"
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          {
            "code": "48155"
          },
          {
            "code": "48500"
          },
          {
            "code": "48510"
          },
          {
            "code": "48520"
          },
          {
            "code": "48540"
          },
          {
            "code": "48545"
          },
          {
            "code": "48547"
          },
          {
            "code": "48548"
          },
          {
            "code": "48554"
          },
          {
            "code": "48556"
          },
          {
            "code": "49000"
          },
          {
            "code": "49002"
          },
          {
            "code": "49010"
          },
          {
            "code": "49020"
          },
          {
            "code": "49040"
          },
          {
            "code": "49060"
          },
          {
            "code": "49203"
          },
          {
            "code": "49204"
          },
          {
            "code": "49205"
          },
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            "code": "49215"
          },
          {
            "code": "49220"
          },
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            "code": "49250"
          },
          {
            "code": "49320"
          },
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            "code": "49321"
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          },
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            "code": "49323"
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          {
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          },
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            "code": "49407"
          },
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            "code": "49505"
          },
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            "code": "49507"
          },
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            "code": "49568"
          },
          {
            "code": "50320"
          },
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            "code": "50340"
          },
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            "code": "50360"
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            "code": "50365"
          },
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          {
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            "code": "58200"
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            "code": "58210"
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            "code": "58240"
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            "code": "58260"
          },
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            "code": "58262"
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            "code": "58275"
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            "code": "58280"
          },
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            "code": "58290"
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          {
            "code": "58291"
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          {
            "code": "58292"
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          {
            "code": "58293"
          },
          {
            "code": "58294"
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            "code": "58951"
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            "code": "58953"
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            "code": "58954"
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            "code": "61750"
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            "code": "62223"
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          {
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            "code": "63276"
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          {
            "code": "64746"
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          {
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            "code": "46744"
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            "code": "46746"
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            "code": "46748"
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            "code": "46750"
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            "code": "46751"
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            "code": "46753"
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            "code": "46754"
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            "code": "46760"
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            "code": "46761"
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            "code": "47100"
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            "code": "47120"
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            "code": "47122"
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            "code": "47125"
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            "code": "47130"
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            "code": "47135"
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            "code": "47140"
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            "code": "47141"
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            "code": "47142"
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            "code": "47300"
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            "code": "47350"
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            "code": "47360"
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            "code": "47361"
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            "code": "47362"
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            "code": "47370"
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            "code": "47380"
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            "code": "47425"
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            "code": "47460"
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            "code": "47480"
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            "code": "47562"
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            "code": "47563"
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            "code": "47564"
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            "code": "47570"
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            "code": "47600"
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            "code": "47605"
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            "code": "47610"
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            "code": "47612"
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            "code": "47620"
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            "code": "47700"
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            "code": "47701"
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            "code": "47711"
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            "code": "47712"
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          {
            "code": "47715"
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            "code": "47720"
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            "code": "47721"
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            "code": "47740"
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            "code": "47741"
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            "code": "47760"
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            "code": "47765"
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            "code": "47780"
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            "code": "47785"
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          {
            "code": "47800"
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            "code": "47801"
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            "code": "47802"
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            "code": "47900"
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            "code": "48000"
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            "code": "48001"
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            "code": "48020"
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            "code": "48100"
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            "code": "48102"
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            "code": "48105"
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            "code": "48120"
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            "code": "48140"
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            "code": "48145"
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            "code": "48146"
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            "code": "48148"
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            "code": "48150"
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            "code": "48152"
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            "code": "48153"
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            "code": "48154"
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            "code": "48155"
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          {
            "code": "48500"
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          {
            "code": "48510"
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            "code": "48520"
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          {
            "code": "48540"
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            "code": "48545"
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            "code": "48547"
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          {
            "code": "48548"
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            "code": "48554"
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          {
            "code": "48556"
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          {
            "code": "49000"
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            "code": "49002"
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            "code": "49010"
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            "code": "49020"
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            "code": "49040"
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            "code": "49060"
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            "code": "49203"
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            "code": "49204"
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            "code": "49205"
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            "code": "49215"
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            "code": "49220"
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            "code": "49250"
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            "code": "49255"
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            "code": "49320"
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            "code": "49321"
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            "code": "49405"
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            "code": "49406"
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            "code": "49407"
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            "code": "49505"
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            "code": "49507"
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            "code": "49560"
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            "code": "49561"
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            "code": "49565"
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            "code": "49566"
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            "code": "49570"
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            "code": "50020"
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            "code": "50220"
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            "code": "50225"
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            "code": "50230"
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            "code": "50236"
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            "code": "50240"
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            "code": "50320"
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            "code": "50340"
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            "code": "50360"
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            "code": "50365"
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            "code": "50370"
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            "code": "50380"
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            "code": "50543"
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            "code": "50545"
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            "code": "50547"
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            "code": "50760"
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            "code": "50780"
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            "code": "50782"
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            "code": "50785"
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            "code": "50800"
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            "code": "50810"
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            "code": "50815"
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            "code": "50947"
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            "code": "50948"
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          {
            "code": "51550"
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            "code": "51555"
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            "code": "51565"
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            "code": "51570"
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            "code": "51575"
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            "code": "51580"
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            "code": "51585"
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            "code": "51590"
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            "code": "51595"
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            "code": "51597"
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            "code": "51800"
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            "code": "51820"
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            "code": "51900"
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            "code": "51920"
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            "code": "51960"
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            "code": "55810"
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            "code": "55812"
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            "code": "55815"
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            "code": "55821"
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            "code": "55831"
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            "code": "55840"
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            "code": "55842"
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            "code": "55845"
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            "code": "55866"
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            "code": "56630"
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            "code": "56631"
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            "code": "56632"
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            "code": "56633"
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            "code": "56634"
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            "code": "56637"
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            "code": "56640"
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            "code": "57267"
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            "code": "58150"
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            "code": "58152"
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            "code": "58180"
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            "code": "58200"
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            "code": "58270"
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            "code": "58275"
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            "code": "58280"
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            "code": "58285"
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            "code": "58290"
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            "code": "58292"
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            "code": "58293"
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            "code": "58294"
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            "code": "58951"
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            "code": "58953"
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            "code": "58954"
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            "code": "58956"
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            "code": "60200"
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            "code": "60210"
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            "code": "60212"
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            "code": "60220"
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            "code": "60225"
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            "code": "60240"
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            "code": "60252"
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            "code": "60254"
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            "code": "60260"
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            "code": "60270"
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            "code": "60271"
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            "code": "60280"
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            "code": "60281"
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            "code": "60500"
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            "code": "60520"
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            "code": "61526"
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            "code": "61530"
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            "code": "61548"
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            "code": "61595"
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            "code": "61596"
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            "code": "99201"
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            "code": "99202"
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          {
            "code": "99203"
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            "code": "99204"
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            "code": "99205"
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          {
            "code": "99212"
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            "code": "99213"
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            "code": "99214"
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          {
            "code": "99215"
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          {
            "code": "99341"
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          {
            "code": "99342"
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            "code": "99343"
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            "code": "99344"
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            "code": "99345"
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          {
            "code": "99347"
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          {
            "code": "99348"
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          {
            "code": "99349"
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          {
            "code": "99350"
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          {
            "code": "G0402"
          },
          {
            "code": "G0438"
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            "code": "G0439"
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        "optionType": "eligiblePopulationExclusion",
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          {
            "code": "G9707"
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      {
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            "code": "4040F",
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      {
        "optionType": "performanceNotMet",
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          {
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              "2P",
              "3P"
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        ],
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    ]
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    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU)",
    "description": "Percentage of patients, regardless of age, who are under the care of an anesthesia practitioner and are admitted to a PACU in which a post-anesthetic formal transfer of care protocol or checklist which includes the key transfer of care elements is utilized",
    "nationalQualityStrategyDomain": "CCC",
    "measureType": "process",
    "measureId": "426",
    "eMeasureId": null,
    "nqfEMeasureId": null,
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    "strata": [
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        "description": "Percentage of patients, regardless of age, who are under the care of an anesthesia practitioner and are admitted to a PACU in which a post-anesthetic formal transfer of care protocol or checklist which includes the key transfer of care elements is utilized",
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    "title": "Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU)",
    "description": "Percentage of patients, regardless of age, who undergo a procedure under anesthesia and are admitted to an Intensive Care Unit (ICU) directly from the anesthetizing location, who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible ICU team or team member",
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    "measureId": "427",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "description": "Percentage of patients, regardless of age, who undergo a procedure under anesthesia and are admitted to an Intensive Care Unit (ICU) directly from the anesthetizing location, who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible ICU team or team member",
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    "category": "quality",
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    "lastPerformanceYear": null,
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    "measureId": "369",
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    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "description": "Patients who were tested for hepatitis B surface antigen (HBsAg) during pregnancy within 280 days prior to delivery",
        "eMeasureUuids": {
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        "name": "hepB"
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    "description": "The percent of patients undergoing breast cancer operations who obtained the diagnosis of breast cancer preoperatively by a minimally invasive biopsy method",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "process",
    "measureId": "263",
    "eMeasureId": null,
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        "description": "The percent of patients undergoing breast cancer operations who obtained the diagnosis of breast cancer preoperatively by a minimally invasive biopsy method",
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    "primarySteward": "American Society of Breast Surgeons",
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    "measureSpecification": {
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    }
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    "metricType": "singlePerformanceRate",
    "title": "Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections",
    "description": "Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed",
    "nationalQualityStrategyDomain": "PS",
    "measureType": "process",
    "measureId": "076",
    "eMeasureId": null,
    "nqfEMeasureId": null,
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    "strata": [
      {
        "description": "Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed",
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    ],
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    "eligibilityOptions": [
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            "code": "36555"
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            "code": "36556"
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            "code": "36558"
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          {
            "code": "36560"
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            "code": "36561"
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            "code": "36563"
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            "code": "36566"
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            "code": "36568"
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            "code": "36569"
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            "code": "36570"
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            "code": "36571"
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            "code": "36578"
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            "code": "36585"
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          {
            "code": "93503"
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        "description": "Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively or intraoperatively",
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            "code": "90953"
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            "code": "90954",
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            "code": "90955",
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            "code": "90956"
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            "code": "90957",
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              "GT"
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            "code": "90958",
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            "code": "90959"
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            "code": "90960"
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            "code": "90961",
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            "code": "90962"
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            "code": "90963",
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            "code": "90964",
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            "code": "90965",
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            "code": "90966",
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              "GQ",
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            "code": "90967",
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            "code": "90968",
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            "code": "90969",
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            "code": "90970",
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            "code": "96161"
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            "code": "99201",
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              "GQ",
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            "code": "99205",
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            "code": "99212",
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              "GQ",
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            "code": "99213",
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            "code": "99214",
            "modifierExclusions": [
              "GQ",
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          },
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            "code": "99215",
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              "GQ",
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          },
          {
            "code": "99241"
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          {
            "code": "99242"
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          {
            "code": "99243"
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          {
            "code": "99244"
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          {
            "code": "99245"
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          {
            "code": "99304"
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          {
            "code": "99305"
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          {
            "code": "99306"
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            "code": "99307",
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          },
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            "code": "99308",
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              "GQ",
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          },
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            "code": "99309",
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          },
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            "code": "99310",
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          },
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            "code": "99315"
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            "code": "99316"
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            "code": "99324"
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            "code": "99325"
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            "code": "99326"
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            "code": "99327"
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          {
            "code": "99328"
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            "code": "99334"
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            "code": "99335"
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            "code": "99336"
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            "code": "99337"
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          {
            "code": "99341"
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            "code": "99342"
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            "code": "99343"
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            "code": "99344"
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            "code": "99345"
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            "code": "99347"
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            "code": "99348"
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            "code": "99349"
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            "code": "99350"
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            "code": "99381"
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            "code": "99382"
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            "code": "99383"
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            "code": "99384"
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            "code": "99385"
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            "code": "99386"
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            "code": "99387"
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            "code": "99391"
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            "code": "99392"
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            "code": "99393"
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            "code": "99394"
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            "code": "99395"
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            "code": "99396"
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            "code": "99397"
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            "code": "99401"
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            "code": "99402"
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            "code": "99403"
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            "code": "99412"
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            "code": "99429"
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            "code": "99512"
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            "code": "G0438",
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          {
            "code": "99281"
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            "code": "99282"
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            "code": "99283"
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            "code": "99284"
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            "code": "99285"
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            "code": "99304"
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          {
            "code": "99305"
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            "code": "99306"
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            "code": "99325"
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            "code": "99326"
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            "code": "99327"
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            "code": "99328"
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            "code": "99334"
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            "code": "99335"
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          {
            "code": "99336"
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            "code": "99337"
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            "code": "99341"
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            "code": "99342"
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            "code": "99343"
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            "code": "99344"
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            "code": "99345"
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            "code": "99347"
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        ],
        "submissionMethods": [
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      },
      {
        "optionType": "performanceMet",
        "qualityCodes": [
          {
            "code": "0517F",
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              "1P",
              "2P",
              "3P",
              "8P"
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          },
          {
            "code": "3285F",
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              "1P",
              "2P",
              "3P",
              "8P"
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      {
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          {
            "code": "3284F",
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        "submissionMethods": [
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      {
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          {
            "code": "3284F",
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              "2P",
              "3P"
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            "modifiers": [
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        ],
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      }
    ]
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Proportion Admitted to Hospice for less than 3 days",
    "description": "Proportion of patients who died from cancer, and admitted to hospice and spent less than 3 days there",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "outcome",
    "measureId": "457",
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    "nqfEMeasureId": null,
    "nqfId": "0216",
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  },
  {
    "category": "quality",
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    "lastPerformanceYear": null,
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    "measureType": "outcome",
    "measureId": "455",
    "eMeasureId": null,
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    "nqfId": "0213",
    "isInverse": true,
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      {
        "description": "Proportion of patients who died from cancer admitted to the ICU in the last 30 days of life",
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    ],
    "isHighPriority": true,
    "primarySteward": "American Society of Clinical Oncology",
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    "measureSets": [
      "generalOncology"
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      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_455_Registry.pdf"
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  },
  {
    "category": "quality",
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    "measureType": "process",
    "measureId": "456",
    "eMeasureId": null,
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    "nqfId": "0215",
    "isInverse": true,
    "strata": [
      {
        "description": "Proportion of patients who died from cancer not admitted to hospice",
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    ],
    "isHighPriority": true,
    "primarySteward": "American Society of Clinical Oncology",
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    "measureSets": [
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  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair",
    "description": "Percentage of patients undergoing any surgery to repair pelvic organ prolapse who sustains an injury to the bladder recognized either during or within 1 month after surgery",
    "nationalQualityStrategyDomain": "PS",
    "measureType": "outcome",
    "measureId": "432",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": true,
    "strata": [
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        "description": "Percentage of patients undergoing any surgery to repair pelvic organ prolapse who sustains an injury to the bladder recognized either during or within 1 month after surgery",
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    "isHighPriority": true,
    "primarySteward": "American Urogynecologic Society",
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    "measureSets": [
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    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_432_Registry.pdf"
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  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair",
    "description": "Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bowel injury at the time of index surgery that is recognized intraoperatively or within 1 month after surgery",
    "nationalQualityStrategyDomain": "PS",
    "measureType": "outcome",
    "measureId": "433",
    "eMeasureId": null,
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    "nqfId": null,
    "isInverse": true,
    "strata": [
      {
        "description": "Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bowel injury at the time of index surgery that is recognized intraoperatively or within 1 month after surgery",
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    ],
    "isHighPriority": true,
    "primarySteward": "American Urogynecologic Society",
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    "measureSets": [
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  {
    "category": "quality",
    "firstPerformanceYear": 2017,
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    "title": "Proportion of Patients Sustaining a Ureter Injury at the Time of any Pelvic Organ Prolapse Repair",
    "description": "Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the ureter recognized either during or within 1 month after surgery",
    "nationalQualityStrategyDomain": "PS",
    "measureType": "outcome",
    "measureId": "434",
    "eMeasureId": null,
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    "isInverse": true,
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        "description": "Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the ureter recognized either during or within 1 month after surgery",
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    "isHighPriority": true,
    "primarySteward": "American Urogynecologic Society",
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    "measureSets": [
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    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_434_Registry.pdf"
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  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Proportion of Patients who Died from Cancer with more than One Emergency Department Visit in the Last 30 Days of Life",
    "description": "Proportion of patients who died from cancer with more than one emergency department visit in the last 30 days of life",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "outcome",
    "measureId": "454",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0211",
    "isInverse": true,
    "strata": [
      {
        "description": "Proportion of patients who died from cancer with more than one emergency department visit in the last 30 days of life",
        "name": "emergencyDepartment"
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    ],
    "isHighPriority": true,
    "primarySteward": "American Society of Clinical Oncology",
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      "registry"
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    "measureSets": [
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    "measureSpecification": {
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  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Proportion Receiving Chemotherapy in the Last 14 Days of Life",
    "description": "Proportion of patients who died from cancer receiving chemotherapy in the last 14 days of life",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "process",
    "measureId": "453",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0210",
    "isInverse": true,
    "strata": [
      {
        "description": "Proportion of patients who died from cancer receiving chemotherapy in the last 14 days of life",
        "name": "chemotherapy"
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    ],
    "isHighPriority": true,
    "primarySteward": "American Society of Clinical Oncology",
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    "measureSets": [
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      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_453_Registry.pdf"
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    "nationalQualityStrategyDomain": "ECC",
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    "measureId": "104",
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    "nqfId": "0390",
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    "nationalQualityStrategyDomain": "ECR",
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    "measureId": "102",
    "eMeasureId": "CMS129v6",
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    "nqfId": "0389",
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        "description": "Percentage of psoriasis patients receiving oral systemic or biologic therapy who meet minimal physician-or patient- reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician-and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment",
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    "isHighPriority": true,
    "primarySteward": "American Academy of Dermatology",
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            "code": "99204",
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            "code": "99205",
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            "code": "99213",
            "modifierExclusions": [
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            "code": "99214",
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            "code": "99215",
            "modifierExclusions": [
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            "code": "99324"
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            "code": "99345"
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            "code": "99350"
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            "code": "99335"
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            "code": "99336"
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            "code": "99337"
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            "code": "99341"
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            "code": "99342"
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            "code": "99343"
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            "code": "99344"
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            "code": "99345"
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            "code": "99347"
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            "code": "99348"
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            "code": "99349"
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            "code": "99350"
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        "optionType": "performanceMet",
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            "code": "G9634"
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        "optionType": "eligiblePopulationException",
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          {
            "code": "G9635"
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        "optionType": "performanceNotMet",
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          {
            "code": "G9636"
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    "category": "quality",
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        "description": "This is a measure based on whether quantitative evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) by immunohistochemistry (IHC) uses the system recommended in the current ASCO/CAP Guidelines for Human Epidermal Growth Factor Receptor 2 Testing in breast cancer",
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    "category": "quality",
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            "code": "70490"
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            "code": "70491"
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            "code": "70492"
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            "code": "72125"
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            "code": "72126"
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            "code": "72127"
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            "code": "72128"
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            "code": "72129"
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            "code": "72130"
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            "code": "72131"
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            "code": "72132"
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            "code": "72133"
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            "code": "72191"
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            "code": "72192"
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            "code": "72193"
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            "code": "72194"
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            "code": "73200"
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            "code": "73201"
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            "code": "73202"
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            "code": "73206"
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            "code": "73700"
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            "code": "73701"
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            "code": "73702"
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            "code": "73706"
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            "code": "74150"
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            "code": "74160"
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            "code": "74170"
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            "code": "74174"
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            "code": "74175"
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            "code": "74176"
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            "code": "74177"
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            "code": "74178"
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            "code": "74261"
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            "code": "74262"
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            "code": "74263"
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            "code": "75571"
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            "code": "75572"
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            "code": "75573"
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            "code": "75574"
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            "code": "76497"
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            "code": "77011"
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            "code": "77013"
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            "code": "77014"
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            "code": "77078"
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            "code": "0042T"
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        "optionType": "eligiblePopulationExclusion",
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    "category": "quality",
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            "code": "34845"
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            "code": "34846"
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            "code": "34847"
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            "code": "34848"
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            "code": "36223"
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            "code": "36224"
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            "code": "36251"
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            "code": "36252"
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            "code": "36254"
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            "code": "36902"
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            "code": "36906"
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            "code": "37183"
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            "code": "37184"
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            "code": "37187"
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            "code": "37188"
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            "code": "37211"
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            "code": "37212"
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            "code": "37213"
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            "code": "37214"
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            "code": "37215"
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            "code": "37216"
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            "code": "37217"
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            "code": "37218"
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            "code": "37220"
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            "code": "37224"
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            "code": "37225"
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            "code": "37227"
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            "code": "37228"
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            "code": "37229"
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            "code": "37230"
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            "code": "37231"
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            "code": "37236"
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            "code": "37238"
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            "code": "37241"
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            "code": "37242"
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            "code": "37243"
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            "code": "37244"
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            "code": "37246"
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            "code": "37247"
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            "code": "37248"
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            "code": "37249"
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            "code": "43260"
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            "code": "43261"
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            "code": "43262"
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            "code": "43263"
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            "code": "43264"
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            "code": "43265"
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            "code": "43274"
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            "code": "43275"
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            "code": "43276"
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            "code": "43277"
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            "code": "43278"
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            "code": "43752"
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            "code": "47537"
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            "code": "49440"
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            "code": "49441"
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            "code": "49442"
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            "code": "49446"
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            "code": "49450"
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            "code": "49451"
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            "code": "49452"
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            "code": "49460"
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            "code": "49465"
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            "code": "50386"
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            "code": "50387"
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            "code": "50389"
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            "code": "50590"
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            "code": "61623"
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            "code": "61630"
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            "code": "61635"
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            "code": "61640"
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            "code": "61645"
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            "code": "61650"
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          {
            "code": "62263"
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            "code": "62264"
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            "code": "62280"
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            "code": "62281"
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            "code": "62282"
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            "code": "62302"
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            "code": "62303"
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            "code": "62304"
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            "code": "62305"
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            "code": "64610"
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            "code": "70010"
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            "code": "70015"
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            "code": "70170"
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            "code": "70332"
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            "code": "70370"
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            "code": "70371"
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            "code": "70390"
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            "code": "71023"
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            "code": "71034"
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            "code": "72240"
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            "code": "72255"
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            "code": "72265"
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            "code": "72270"
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            "code": "72275"
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            "code": "72285"
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            "code": "72295"
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          {
            "code": "73040"
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          {
            "code": "73085"
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            "code": "73115"
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            "code": "73525"
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            "code": "73580"
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            "code": "73615"
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            "code": "74190"
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            "code": "74210"
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            "code": "74220"
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            "code": "74230"
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            "code": "74235"
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            "code": "74240"
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            "code": "74249"
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            "code": "74251"
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            "code": "74270"
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            "code": "74280"
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          {
            "code": "74283"
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          {
            "code": "74290"
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          {
            "code": "74300"
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            "code": "74328"
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            "code": "74329"
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            "code": "74330"
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            "code": "74340"
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            "code": "74355"
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            "code": "74360"
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            "code": "74363"
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            "code": "74425"
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            "code": "74430"
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            "code": "74440"
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            "code": "74445"
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          {
            "code": "74450"
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          {
            "code": "74455"
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            "code": "74470"
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            "code": "74485"
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            "code": "74740"
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            "code": "74742"
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            "code": "75600"
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            "code": "75605"
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            "code": "75625"
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            "code": "75630"
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            "code": "75658"
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            "code": "75705"
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            "code": "75710"
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            "code": "75716"
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            "code": "75726"
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            "code": "75731"
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            "code": "75733"
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            "code": "75736"
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            "code": "75741"
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            "code": "75743"
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            "code": "75756"
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            "code": "75801"
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            "code": "75805"
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            "code": "75807"
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            "code": "75809"
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            "code": "75810"
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            "code": "75820"
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            "code": "75822"
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          {
            "code": "75825"
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            "code": "75827"
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            "code": "75831"
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            "code": "75833"
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            "code": "75840"
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            "code": "75842"
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            "code": "75860"
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            "code": "75870"
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            "code": "75872"
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            "code": "75880"
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            "code": "75889"
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            "code": "75901"
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            "code": "75902"
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            "code": "75952"
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            "code": "75953"
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            "code": "75954"
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            "code": "75956"
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            "code": "75958"
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            "code": "75959"
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            "code": "75970"
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            "code": "75984"
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            "code": "76000"
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            "code": "76001"
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            "code": "76080"
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            "code": "76120"
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    "title": "Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS)",
    "description": "Percent of asymptomatic patients undergoing CAS who experience stroke or death following surgery while in the hospital",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "outcome",
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    "nqfId": "1543",
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    "isHighPriority": true,
    "primarySteward": "Society for Vascular Surgeons",
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    "measureSets": [
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      "vascularSurgery"
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    "isRegistryMeasure": false,
    "measureSpecification": {
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    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
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    "measureType": "outcome",
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    "eMeasureId": null,
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    "nqfId": "1540",
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        "description": "Percent of asymptomatic patients undergoing CEA who experience stroke or death following surgery while in the hospital",
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    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
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    "nationalQualityStrategyDomain": "PS",
    "measureType": "outcome",
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    "eMeasureId": null,
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    "nqfId": null,
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    "strata": [
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        "description": "Inpatients assigned to endovascular treatment for obstructive arterial disease, the percent of patients who undergo unplanned major amputation or surgical bypass within 48 hours of the index procedure",
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            "code": "G9641"
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        "description": "Percentage of patients aged birth and older referred to a physician (preferably a physician specially trained in disorders of the ear) for an otologic evaluation subsequent to an audiologic evaluation after presenting with acute or chronic dizziness",
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          {
            "code": "92550"
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          {
            "code": "92557"
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            "code": "92567"
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          {
            "code": "92568"
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          {
            "code": "92570"
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          {
            "code": "92575"
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        "qualityCodes": [
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            "code": "G8856"
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        "submissionMethods": [
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      {
        "optionType": "eligiblePopulationException",
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        "submissionMethods": [
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  {
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    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
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    "nationalQualityStrategyDomain": "ECC",
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    "nationalQualityStrategyDomain": "ECC",
    "measureType": "process",
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    "measureId": "177",
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    "nationalQualityStrategyDomain": "ECC",
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    }
  },
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    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Tobacco Use and Help with Quitting Among Adolescents",
    "description": "The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user",
    "nationalQualityStrategyDomain": "CPH",
    "measureType": "process",
    "measureId": "402",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "description": "The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user",
        "name": "tobacco"
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    ],
    "isHighPriority": false,
    "primarySteward": "National Committee for Quality Assurance",
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    "measureSets": [
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      "internalMedicine",
      "cardiology",
      "dermatology",
      "emergencyMedicine",
      "gastroenterology",
      "generalSurgery",
      "generalOncology",
      "hospitalists",
      "neurology",
      "obstetricsGynecology",
      "ophthalmology",
      "orthopedicSurgery",
      "otolaryngology",
      "physicalMedicine",
      "preventiveMedicine",
      "rheumatology",
      "thoracicSurgery",
      "urology",
      "vascularSurgery",
      "mentalBehavioralHealth",
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      "generalPracticeFamilyMedicine",
      "pediatrics"
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    "isRegistryMeasure": false,
    "measureSpecification": {
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  },
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    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report",
    "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": "PS",
    "measureType": "process",
    "measureId": "353",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "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",
        "name": "kneeReplacement"
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    ],
    "isHighPriority": true,
    "primarySteward": "American Association of Hip and Knee Surgeons",
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    "measureSets": [
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    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_353_Registry.pdf"
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  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet",
    "description": "Percentage of patients regardless of age undergoing a total knee replacement who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet",
    "nationalQualityStrategyDomain": "PS",
    "measureType": "process",
    "measureId": "352",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
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        "description": "Percentage of patients regardless of age undergoing a total knee replacement who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet",
        "name": "kneeReplacement"
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    ],
    "isHighPriority": true,
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  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
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    "title": "Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy",
    "description": "Percentage of patients regardless of age undergoing a total knee replacement with documented shared decision-making with discussion of conservative (non-surgical) therapy (e.g., non-steroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure",
    "nationalQualityStrategyDomain": "CCC",
    "measureType": "process",
    "measureId": "350",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
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    "strata": [
      {
        "description": "Percentage of patients regardless of age undergoing a total knee replacement with documented shared decision- making with discussion of conservative (non-surgical) therapy (e.g., non-steroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure",
        "name": "kneeReplacement"
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    "primarySteward": "American Association of Hip and Knee Surgeons",
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    "category": "quality",
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    "nationalQualityStrategyDomain": "PS",
    "measureType": "process",
    "measureId": "351",
    "eMeasureId": null,
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        "description": "Percentage of patients regardless of age undergoing a total knee replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g. history of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke)",
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    "category": "quality",
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    "nationalQualityStrategyDomain": "ECR",
    "measureType": "process",
    "measureId": "450",
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    "nqfEMeasureId": null,
    "nqfId": "1858",
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        "description": "Proportion of female patients (aged 18 years and older) with AJCC stage I (T1c) – III, human epidermal growth factor receptor 2 (HER2) positive breast cancer receiving adjuvant chemotherapy who are also receiving trastuzumab",
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    "primarySteward": "American Society of Clinical Oncology",
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    "nationalQualityStrategyDomain": "ECC",
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          {
            "code": "99336"
          },
          {
            "code": "99337"
          },
          {
            "code": "99341"
          },
          {
            "code": "99342"
          },
          {
            "code": "99343"
          },
          {
            "code": "99344"
          },
          {
            "code": "99345"
          },
          {
            "code": "99347"
          },
          {
            "code": "99348"
          },
          {
            "code": "99349"
          },
          {
            "code": "99350"
          },
          {
            "code": "G0402"
          }
        ],
        "sexCode": "F",
        "submissionMethods": [
          "claims"
        ]
      }
    ],
    "performanceOptions": [
      {
        "optionType": "eligiblePopulationExclusion",
        "qualityCodes": [
          {
            "code": "G9694"
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "optionType": "performanceMet",
        "qualityCodes": [
          {
            "code": "0509F",
            "modifierExclusions": [
              "1P",
              "2P",
              "3P",
              "8P"
            ]
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      },
      {
        "optionType": "performanceNotMet",
        "qualityCodes": [
          {
            "code": "0509F",
            "modifierExclusions": [
              "1P",
              "2P",
              "3P"
            ],
            "modifiers": [
              "8P"
            ]
          }
        ],
        "submissionMethods": [
          "claims"
        ]
      }
    ]
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "multiPerformanceRate",
    "title": "Use of High-Risk Medications in the Elderly",
    "description": "Percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported.\na. Percentage of patients who were ordered at least one high-risk medication. \nb. Percentage of patients who were ordered at least two different high-risk medications.",
    "nationalQualityStrategyDomain": "PS",
    "measureType": "process",
    "measureId": "238",
    "eMeasureId": "CMS156v5",
    "nqfEMeasureId": null,
    "nqfId": "0022",
    "isInverse": true,
    "strata": [
      {
        "description": "Patients with an order for at least one high-risk medication during the measurement period.",
        "name": "overall",
        "eMeasureUuids": {
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          "denominatorUuid": "07F04D61-0383-487E-942C-690BBBC6437D",
          "numeratorUuid": "7A0001AC-4BE0-4FAA-94AE-4843C9FFFCA8"
        }
      },
      {
        "description": "Patients with an order for at least two different high-risk medications during the measurement period.",
        "name": "2+",
        "eMeasureUuids": {
          "initialPopulationUuid": "BC02D7CE-7133-46C6-8592-658668B09948",
          "denominatorUuid": "00401314-1B01-4896-A9FC-E991CDF29B6B",
          "numeratorUuid": "FA7BF805-C21E-4077-B43E-C63F8D17B5CF"
        }
      }
    ],
    "isHighPriority": true,
    "primarySteward": "National Committee for Quality Assurance",
    "submissionMethods": [
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      "registry"
    ],
    "measureSets": [],
    "overallAlgorithm": "overallStratumOnly",
    "eMeasureUuid": "40280381-52fc-3a32-0153-56d2b4f01ae5",
    "isRegistryMeasure": false,
    "cpcPlusGroup": "B",
    "measureSpecification": {
      "electronicHealthRecord": "https://qpp.cms.gov/docs/ecqm-specs/2017/EC_CMS156v5_NQF0022_HighRisk_Med_Elderly/CMS156v5.html",
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_238_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Use of Imaging Studies for Low Back Pain",
    "description": "Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis.",
    "nationalQualityStrategyDomain": "ECR",
    "measureType": "process",
    "measureId": "312",
    "eMeasureId": "CMS166v6",
    "nqfEMeasureId": null,
    "nqfId": "0052",
    "isInverse": false,
    "strata": [
      {
        "description": "Patients without an imaging study conducted on the date of the outpatient or emergency department visit or in the 28 days following the outpatient or emergency department visit",
        "eMeasureUuids": {
          "initialPopulationUuid": "45D3A3ED-A7D6-45B9-AC95-647BFFE7018E",
          "denominatorUuid": "0E27156C-B8EB-48E7-A588-4AB97A0914E1",
          "numeratorUuid": "13C60632-9CF4-491B-82E9-A06118111C44",
          "denominatorExclusionUuid": "0E9E3C94-6AA0-4C3C-A311-72CB0F2698B6"
        },
        "name": "noStudy28Days"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "National Committee for Quality Assurance",
    "submissionMethods": [
      "electronicHealthRecord",
      "registry"
    ],
    "measureSets": [
      "orthopedicSurgery",
      "physicalMedicine",
      "generalPracticeFamilyMedicine"
    ],
    "eMeasureUuid": "40280381-51f0-825b-0152-22ba7621182e",
    "isRegistryMeasure": false,
    "cpcPlusGroup": "C",
    "measureSpecification": {
      "electronicHealthRecord": "https://qpp.cms.gov/docs/ecqm-specs/2017/EC_CMS166v6_NQF0052_Low_Back_Pain/CMS166v6.html"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "singlePerformanceRate",
    "title": "Varicose Vein Treatment with Saphenous Ablation: Outcome Survey",
    "description": "Percentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease specific patient reported outcome survey instrument after treatment",
    "nationalQualityStrategyDomain": "ECC",
    "measureType": "outcome",
    "measureId": "420",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [
      {
        "description": "Percentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease specific patient reported outcome survey instrument after treatment",
        "name": "CEAP_C2-S"
      }
    ],
    "isHighPriority": true,
    "primarySteward": "Society of Interventional Radiology ",
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [],
    "isRegistryMeasure": false,
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2017_Measure_420_Registry.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "multiPerformanceRate",
    "title": "Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents",
    "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.\n\n - Percentage of patients with height, weight, and body mass  index (BMI) percentile documentation\n - Percentage of patients with counseling for nutrition\n - Percentage of patients with counseling for physical activity",
    "nationalQualityStrategyDomain": "CPH",
    "measureType": "process",
    "measureId": "239",
    "eMeasureId": "CMS155v5",
    "nqfEMeasureId": null,
    "nqfId": "0024",
    "isInverse": false,
    "strata": [
      {
        "description": "Patients who had a height, weight and body mass index (BMI) percentile recorded during the measurement period",
        "eMeasureUuids": {
          "initialPopulationUuid": "0ADE9325-3FB7-402F-AD89-34C9F2753D03",
          "denominatorUuid": "933D86C8-2C2B-4AFF-AE81-DF2F9882A3A4",
          "numeratorUuid": "61887626-5457-484C-A02D-75EF8547F559",
          "denominatorExclusionUuid": "6938F4DD-D5AB-4C40-BA03-EB0F0959615C",
          "strata": [
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            "37B55C43-F2BF-4CC2-94A8-73389186206D"
          ]
        },
        "name": "BMI"
      },
      {
        "description": "Patients who had counseling for nutrition during a visit that occurs during the measurement period",
        "eMeasureUuids": {
          "initialPopulationUuid": "25286925-4221-4396-9DE0-60EA606924DF",
          "denominatorUuid": "CFB8E3E2-FF4F-4D25-B613-7EC142BAE8A9",
          "numeratorUuid": "EEAD441F-B3B2-4DC9-A890-B35E14B38EA7",
          "denominatorExclusionUuid": "A399FA9C-48CF-41E5-812A-3445188B8301",
          "strata": [
            "5BC68B5A-E944-46B9-9DC0-0A60FF869D92",
            "E76F6606-1DC9-40DE-8A34-5B4B4E859152"
          ]
        },
        "name": "nutrition"
      },
      {
        "description": "Patients who had counseling for physical activity during a visit that occurs during the measurement period",
        "eMeasureUuids": {
          "initialPopulationUuid": "48747E9D-674C-4013-9585-268114190119",
          "denominatorUuid": "208B74F2-6592-4381-BEC1-EB136004C3B2",
          "numeratorUuid": "21409D88-B5E3-4745-8DE2-D99DBB9F4DF0",
          "denominatorExclusionUuid": "507F7EC3-D380-48BE-B920-ABB1EB258256",
          "strata": [
            "E0CD71AE-5041-45A3-9AAA-9C8506765238",
            "C19E3A3C-0CF3-4FC2-B084-DEAB9B9F9CB9"
          ]
        },
        "name": "physicalActivity"
      }
    ],
    "isHighPriority": false,
    "primarySteward": "National Committee for Quality Assurance",
    "submissionMethods": [
      "electronicHealthRecord",
      "registry"
    ],
    "measureSets": [
      "pediatrics"
    ],
    "eMeasureUuid": "40280381-51f0-825b-0152-22b695b217dc",
    "overallAlgorithm": "simpleAverage",
    "isRegistryMeasure": false,
    "measureSpecification": {
      "electronicHealthRecord": "https://qpp.cms.gov/docs/ecqm-specs/2017/EC_CMS155v5_NQF0024_Weight_Assess_Counseling/CMS155v5.html"
    }
  },
  {
    "measureId": "AAAAI2",
    "title": "Asthma: Assessment of Asthma Control – Ambulatory Care Setting",
    "description": "Percentage of patients aged 5 years and older with a diagnosis of asthma who were evaluated at least once during the measurement period for asthma control (comprising asthma impairment and asthma risk). National Quality Strategy Domain: Effective Clinical Care Process Measure",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAAAI5",
    "title": "Allergen Immunotherapy Treatment: Allergen Specific Immunoglobulin E (IgE) Sensitivity Assessed and Documented Prior to Treatment",
    "description": "Percentage of patients aged 5 years and older who were assessed for IgE sensitivity to allergens prior to initiating allergen immunotherapy AND results documented in the medical record.National Quality Strategy Domain: Patient Safety Process Measure",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAAAI6",
    "title": "Documentation of Clinical Response to Allergen Immunotherapy within One Year",
    "description": "Percentage of patients aged 5 years and older who were evaluated for clinical improvement and efficacy within one year after initiating allergen immunotherapy AND assessment documented in the medical record. National Quality Strategy Domain: Communication and Care Coordination Process Measure",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAAAI8",
    "title": "Achievement of Projected Effective Dose of Standardized Allergens for Patient Treated With Allergen Immunotherapy for at Least One Year",
    "description": "Proportion of patients receiving subcutaneous allergen immunotherapy that contains at least one standardized extract (mite, ragweed, grass, and/or cat) who achieved the projected effective dose for all included standardized allergen extract(s) after at least one year of treatment. National Quality Strategy Domain: Effective Clinical Care Outcome Measure",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAAAI9",
    "title": "Assessment of Asthma Symptoms Prior to Administration of Allergen Immunotherapy Injection(s)",
    "description": "Percentage of patients aged 5 years and older with a diagnosis of asthma who are receiving subcutaneous allergen immunotherapy with a documented assessment of asthma symptoms prior to administration of allergen immunotherapy injections. National Quality Strategy Domain: Patient Safety Process Measure",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAAAI11",
    "title": "Asthma Assessment and Classification",
    "description": "Percentage of patients aged 5 years and older with asthma and documentation of an asthma assessment and classification. National Quality Strategy Domain: Effective Clinical Care Process Measure",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAAAI12",
    "title": "Lung Function/Spirometry Evaluation",
    "description": "Percentage of patients aged 5 years and older with asthma and documentation of a spirometry evaluation. National Quality Strategy Domain: Effective Clinical Care Process Measure",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAAAI17",
    "title": "Asthma Control: Minimal Important Difference Improvement",
    "description": "Percentage of patients aged 12 years and older whose asthma is not well-controlled as indicated by the Asthma Control Test, Asthma Control Questionnaire, or Asthma Therapy Assessment Questionnaire and who demonstrated a minimal important difference improvement upon a subsequent office visit during the 12-month reporting period. National Quality Strategy Domain: Person and Caregiver-Centered Experience and Outcomes Outcome Measure",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAAAI18",
    "title": "Penicillin Allergy: Appropriate Removal or Confirmation",
    "description": "Percentage of patients, regardless of age, with a primary diagnosis of penicillin or ampicillin/amoxicillin allergy, who underwent elective skin testing or antibiotic challenge that resulted in the removal of the penicillin or ampicillin/amoxicillin allergy label from the medical record if negative or confirmation of the penicillin or ampicillin/amoxicillin allergy label if positive. National Quality Strategy Domain: Communication and Care Coordination Outcome Measure",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAAAI19",
    "title": "Asthma: Pharmacologic Therapy for Persistent Asthma – Ambulatory Care Setting",
    "description": "Percentage of patients aged 5 years and older with a diagnosis of persistent asthma who were prescribed long-term control medication\n\nThis measure will be calculated with three rates:\n\nRate 1: Patients prescribed inhaled corticosteroids (ICS) as their long-term control medication\nRate 2: Patients prescribed alternative long-term control medications (non-ICS)\nRate 3: Total patients prescribed long-term control medication",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "ICS",
        "description": "Patients prescribed inhaled corticosteroids (ICS) as their long-term control medication"
      },
      {
        "name": "nonICS",
        "description": "Patients prescribed alternative long-term control medications (non-ICS)"
      },
      {
        "name": "overall",
        "description": "Total patients prescribed long-term control medication"
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAD1",
    "title": "Psoriasis: Assessment of Psoriasis Disease Activity",
    "description": "This measure evaluates the percentage of patients with plaque psoriasis with documented assessment of disease activity using a validated scale.\n\n Percentage of patients with plaque psoriasis who have disease activity assessed by using one of the listed measures or validated instruments/ tools at least once during the performance period.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAD’s DataDerm™ (American Academy of Dermatology)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAD2",
    "title": "Psoriasis: Screening for Psoriatic Arthritis",
    "description": "Patients with psoriasis are at an increased risk of having psoriatic arthritis. This measure seeks for dermatologists to actively assess for psoriatic arthritis as to relieve symptoms, prevent structural damage, and improve quality of life.\n\n Percentage of patients with diagnosis of psoriasis who are screened for psoriatic arthritis at least once during the performance period.",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAD’s DataDerm™ (American Academy of Dermatology)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "This measure evaluates the number of inappropriately utilized Mohs surgeries to treat primary superficial basal cell carcinomas (BCCs) on the trunk in immune-competent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with AUC and should result in healthcare savings. (Inverse Measure: Low count indicates better performance)\n\n 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™ (American Academy of Dermatology)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAD4",
    "title": "Basal Cell Carcinoma/Squamous Cell Carcinoma: Mohs Surgery for Squamous Cell Carcinoma in Situ or Keratoacanthoma Type Squamous Cell Carcinoma 1 cm or Smaller on the Trunk",
    "description": "This measure evaluates the number of inappropriately utilized Mohs surgeries to treat pathologically-proven primary squamous cell carcinomas in situ (SCCis) of any size on the trunk and keratoacanthoma (SCC-KA) on the trunk that are 1 cm or smaller in immunocompetent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with AUC and should result in healthcare savings. (Inverse Measure: Low count indicates better performance)\n\n The percentage of immune‐competent patients with pathologically‐proven primary squamous carcinoma in situ (SCCis) lesions of any size on the trunk (chest, back, abdomen) or keratoacanthoma type squamous cell carcinoma (SCC‐KA) lesions 1 cm or smaller 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™ (American Academy of Dermatology)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAD5",
    "title": "Biopsy Reporting Time - Clinician to Patient",
    "description": "Length of time taken from when a biopsy is performed to when a patient is notified by the biopsying physician that he or she has cutaneous basal or squamous cell carcinoma (including in situ disease). This measure evaluates the reporting time between the biopsying clinician and patient.\n\n 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": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAD’s DataDerm™ (American Academy of Dermatology)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Effective Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ARCO12",
    "title": "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) in Collaboration with ReportingMD, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ARCO13",
    "title": "Ischemic stroke patients management -",
    "description": "o This measure will be calculated with 4 performance rates:\nRate 1: The percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge;\nRate 2: The percent of ischemic stroke patients prescribed anticoagulation therapy at hospital discharge Rate;\nRate 3: The percent of ischemic stroke patients who had antithrombotic therapy administered by end of hospital day two;\nRate 4: 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 Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "sumNumerators",
    "strata": [
      {
        "name": "antithrombotic",
        "description": "The percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge;"
      },
      {
        "name": "anticoagulation",
        "description": "The percent of ischemic stroke patients prescribed anticoagulation therapy at hospital discharge Rate;"
      },
      {
        "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": "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": "Affordable Care: Overuse/Waste, Person- and Family-Centered Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "National Osteoporosis Foundation and National Bone Health Alliance",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ARCO7",
    "title": "Laboratory Investigation for Secondary Causes of Fracture",
    "description": "Percentage of patients age 50 and over with fragility fracture who have had appropriate laboratory investigation for secondary causes of fracture ordered or performed prior to discharge from inpatient status.",
    "nationalQualityStrategyDomain": "Prevention and Treatment of Cardiovascular Disease: Healthy Lifestyle Behaviors",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "American College of Rheumatology - RISE Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ARCO14",
    "title": "Gout: ULT Therapy",
    "description": "Percentage of patients aged 18 and older with a diagnosis of gout and either tophus/tophi or at least two gout flares (attacks) in the past year who have a serum urate level > 6.0 mg/dL, who are prescribed urate lowering therapy (ULT)",
    "nationalQualityStrategyDomain": "Effective Communication and Care Coordination: Quality of Life/Functional Status",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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) in Collaboration with ReportingMD, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACCCath1",
    "title": "Stroke intra or post PCI procedure in patients without CABG or other major surgeries during admission.",
    "description": "Percent of patients, age 18 years and older, undergoing isolated PCI procedure (defined by no CABG or other major surgery during episode of care) who have an intra or post procedure stroke (i.e., any confirmed a loss of neurological function caused by an ischemic or hemorrhagic event with residual symptoms) lasting at least 24 hours after onset or leading to death.\n\nThis measure evaluates the occurrence of stroke as an outcome of a percutaneous coronary intervention (PCI) during a patient’s episode of care.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "ACCF CathPCI Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACCCath2",
    "title": "New requirement for dialysis post PCI in patients without CABG or other major surgeries during admission.",
    "description": "Percent of patients, age 18 years and older, undergoing isolated PCI procedure (defined by no CABG or other major surgery during episode of care) who have a new requirement for renal dialysis intra or post PCI procedure.\n\nThis measure evaluates the occurrence of the new need for dialysis as an outcome of a percutaneous coronary intervention (PCI) during a patient’s episode of care.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "ACCF CathPCI Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACCCath3",
    "title": "Vascular access site injury requiring treatment or major bleeding post PCI in patients without CABG or other major surgeries during admission.",
    "description": "The number of patients, age 18 years and older, undergoing isolated PCI procedure (defined by no CABG or other major surgery during episode of care) who have an intra or post procedure major bleeding event or an intra or post procedure vascular complication requiring treatment.\n\nMajor access site related injury requiring treatment includes: access site occlusion, peripheral embolization, dissection, pseudo-aneurysm, AV fistulas requiring treatment anytime from the procedure until discharge.\n\nMajor bleeding is defined as bleeding at access site, hematomas at access site, or retroperitoneal bleeds that occur within 72 hours of the procedure.  To qualify the event must be associated with a hemoglobin drop of >3 g/dL; or transfusion of whole or packed red blood cells, or a procedural intervention/surgery at the bleeding site to reverse/stop or correct the bleeding.\n\nThis measure evaluates the occurrence of vascular site injury requiring treatment or major bleeding as outcomes of a percutaneous coronary intervention (PCI) during a patient’s episode of care.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "ACCF CathPCI Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACCCath4",
    "title": "Cardiac tamponade post PCI in patients without CABG or other major surgery during admission.",
    "description": "The number of patients, age 18 years and older, undergoing isolated PCI procedure (defined by no CABG or other major surgery during episode of care) who have a cardiac tamponade intra or post procedure.\n\nThis measure evaluates the occurrence of cardiac tamponade as an outcome of a percutaneous coronary intervention (PCI) during a patient’s episode of care.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "ACCF CathPCI Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACCCath5",
    "title": "STEMI patients receiving immediate PCI within 90 minutes.",
    "description": "Percentage of patients diagnosed with a STEMI and treated with a PCI who have the first reperfusion device deployed within 90 minutes or less of their arrival to the hospital, or diagnosis with STEMI.\n\nThis measure reflects the processes of care and current guidelines associated with the treatment of patients experiencing ST elevated myocardial infarctions (STEMI).",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ACCF CathPCI Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACCCath6",
    "title": "ACE-I or ARB prescribed at discharge for patients with an ejection fraction < 40% who had a PCI during the episode of care.",
    "description": "Percentage of patients, age 18 years and older, with a left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB at hospital discharge.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ACCF CathPCI Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACCCath8",
    "title": "Percutaneous Coronary Intervention (PCI): Post-procedural Optimal Medical Therapy",
    "description": "Percentage of patients aged 18 years and older for whom PCI is performed who are prescribed optimal medical therapy at discharge.\n\nThis metric evaluates the process of care associated with the multi-society guidelines recommendations.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ACCF CathPCI Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACCCath9",
    "title": "PCI procedures that were inappropriate for patients with Acute Coronary Syndrome (ACS).",
    "description": "Proportion of PCI procedures for patients with Acute Coronary Syndrome, that were evaluated as “Inappropriate”, meaning coronary revascularization is not generally acceptable and is not a reasonable approach for the indication and is unlikely to improve the patients’ health outcomes or survival.",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ACCF CathPCI Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACCCath13",
    "title": "Cardiac Rehabilitation Patient Referral From an Inpatient Setting",
    "description": "Percentage of patients admitted to a hospital with a primary diagnosis of an acute myocardial infarction or chronic stable angina or who during hospitalization have undergone a percutaneous coronary intervention (PCI),  who are referred to an early outpatient cardiac rehabilitation/secondary prevention program.",
    "nationalQualityStrategyDomain": "Community/Population Health",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ACCF CathPCI Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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  psychiatric or behavioral disorders",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Neurology",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAN9",
    "title": "Querying about Symptoms of Autonomic Dysfunction",
    "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.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Neurology",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAN10",
    "title": "Falls screening",
    "description": "Percentage of patients with Parkinson’s disease, multiple sclerosis, distal symmetric polyneuropathy, ALS, epilepsy, dementia who were screened for falls at least annually",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Neurology",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 polyneuropathy who had screening tests for\ndiabetes (eg fasting blood sugar test, a hemoglobin A1C, or a 2 hour Glucose Tolerance Test) reviewed, requested or ordered\nwhen seen for an initial evaluation for distal symmetric polyneuropathy.",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Neurology",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAN2",
    "title": "Screening for Unhealthy Alcohol Use",
    "description": "Percentage of patients age 18 years and older with a diagnosis of DSP who were screened with a validated screening instrument for unhealthy alcohol use* at their initial evaluation, and if screening was positive, brief counseling provided.\n\n*Unhealthy alcohol use covers a spectrum that is associated with varying degrees of risk to health. Categories representing unhealthy alcohol use include risky use, problem drinking, harmful use, and alcohol abuse, and the less common but more severe alcoholism and alcohol dependence.",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Neurology",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "American Academy of Neurology",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAN11",
    "title": "Overuse of Opioid and Barbiturate 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": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Neurology",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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\n physical activity for patients with MS in the past 12 months.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Neurology",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS1",
    "title": "Corneal Graft Surgery - Post-operative improvement in visual acuity of 20/40 or greater",
    "description": "Percentage of corneal graft surgery patients with a visual acuity of 20/40 or greater within 90 days following surgery.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS4",
    "title": "Glaucoma - Intraocular Pressure Reduction Following Laser Trabeculoplasty",
    "description": "Percentage of patients underwent laser trabeculoplasty who had IOP reduced by 20% from their pretreatment level   Rationale: Intraocular pressure is the only modifiable risk factor so control of IOP is relevant to clinical outcome",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS7",
    "title": "Amblyopia - Interocular Visual Acuity",
    "description": "Percentage of newly diagnosed amblyopic patients with a corrected interocular visual acuity difference of less than 0.23 logMAR within 6 months of first diagnosis",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS19",
    "title": "Chronic Anterior Uveitis -  Post-treatment Grade 0 anterior chamber cells",
    "description": "Percentage of patients with chronic 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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS22",
    "title": "Giant Cell Arteritis:  Absence of fellow eye involvement after corticosteroid treatment",
    "description": "Percentage of patients without fellow eye involvement 1-26 weeks after initiating corticosteroids 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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS23",
    "title": "Refractive Surgery: Postoperative Improvement in Uncorrected Visual Acuity of 20/20 or better",
    "description": "Percentage of patients with an uncorrected visual acuity (UCVA) of 20/20 or better",
    "nationalQualityStrategyDomain": "Outcome",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Outcome",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "Q415",
    "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 within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and 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": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "Q416",
    "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 within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and 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\n (INVERSE Measure: Lower score indicates better performance)",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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\n (INVERSE Measure: Lower score indicates better performance)",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 or 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": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACEP24",
    "title": "Pregnancy Test for Female Abdominal Pain Patients",
    "description": "Percentage of all female patients ages 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": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACEP25",
    "title": "Tobacco Use: Screening and Cessation Intervention",
    "description": "Percentage of asthma or COPD patients aged 18 years and older who were screened for tobacco use 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": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACEP26",
    "title": "Sepsis Management: Septic Shock: Lactate Level Measurement",
    "description": "Percentage of emergency department visits for patients aged 18 years and older with septic shock who had a serum lactate level ordered during the emergency department visit",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACEP27",
    "title": "Sepsis Management: Septic Shock: Antibiotics Ordered",
    "description": "Percentage of emergency department visits for patients aged 18 years and older with septic shock who had an order for antibiotics during the emergency department visit",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACEP28",
    "title": "Sepsis Management: Septic Shock: Fluid Resuscitation",
    "description": "Percentage of emergency department visits for patients aged 18 years and older with septic shock who had an order for ≥ 1 L of crystalloids during the emergency department visit",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACEP30",
    "title": "Sepsis Management: Septic Shock: Lactate Clearance Rate ≥ 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 second 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": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACEP31",
    "title": "Emergency Medicine: 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": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACEP32",
    "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients",
    "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients\n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 (80k +)",
    "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients\n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACEP35",
    "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in High Volume EDs (60k-79,999)",
    "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients\n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients\n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients\n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients\n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 Eds",
    "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients\n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACEP40",
    "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients",
    "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients  (Excluding Psych and Mental Health, and Transfer Patients)\n\n2. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Psych and Mental Health Patients\n\n3. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients (Transfer from ED)\n\n4. ED Median Time from ED arrival to ED departure for Discharged ED patients for Pediatric Patients (All Eligible Patients\n\n (Lower score indicates better performance)",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients  (Excluding Psych and Mental Health, and Transfer Patients)\n\n2. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Psych and Mental Health Patients\n\n3. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients (Transfer from ED)\n\n4. ED Median Time from ED arrival to ED departure for Discharged ED patients for Pediatric Patients (All Eligible Patients\n\n (Lower score indicates better performance)",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients  (Excluding Psych and Mental Health, and Transfer Patients)\n\n2. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Psych and Mental Health Patients\n\n3. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients (Transfer from ED)\n\n4. ED Median Time from ED arrival to ED departure for Discharged ED patients for Pediatric Patients (All Eligible Patients\n\n (Lower score indicates better performance)",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACEP44",
    "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Average Volume EDs (40k-59,999)",
    "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients  (Excluding Psych and Mental Health, and Transfer Patients)\n\n2. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Psych and Mental Health Patients\n\n3. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients (Transfer from ED)\n\n4. ED Median Time from ED arrival to ED departure for Discharged ED patients for Pediatric Patients (All Eligible Patients\n\n (Lower score indicates better performance)",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients  (Excluding Psych and Mental Health, and Transfer Patients)\n\n2. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Psych and Mental Health Patients\n\n3. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients (Transfer from ED)\n\n4. ED Median Time from ED arrival to ED departure for Discharged ED patients for Pediatric Patients (All Eligible Patients\n\n (Lower score indicates better performance)",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients  (Excluding Psych and Mental Health, and Transfer Patients)\n\n2. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Psych and Mental Health Patients\n\n3. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients (Transfer from ED)\n\n4. ED Median Time from ED arrival to ED departure for Discharged ED patients for Pediatric Patients (All Eligible Patients\n\n (Lower score indicates better performance)",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients  (Excluding Psych and Mental Health, and Transfer Patients)\n\n2. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Psych and Mental Health Patients\n\n3. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients (Transfer from ED)\n\n4. ED Median Time from ED arrival to ED departure for Discharged ED patients for Pediatric Patients (All Eligible Patients\n\n (Lower score indicates better performance)",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACEP48",
    "title": "Sepsis Management: Septic Shock: Blood Cultures Ordered",
    "description": "Percentage of emergency department visits for patients aged 18 years and older with septic shock who had a blood culture ordered during the emergency department visit",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACEP49",
    "title": "Emergency Medicine: Appropriate Use of Imaging for Recurrent Renal Colic",
    "description": "Percentage of emergency department (ED) visits for patients aged 18-50 years presenting with flank pain with a history of kidney stones during which no imaging is ordered, OR appropriate imaging (i.e., plain film radiography or ultrasound) is ordered",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "PPRNET20",
    "title": "Herpes Zoster (Shingles) Vaccination",
    "description": "The percentage of patients 60 years of age and older who have a Varicella Zoster (shingles) vaccination",
    "nationalQualityStrategyDomain": "Community/Population Health",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "PPRNet",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 vaccination.",
    "nationalQualityStrategyDomain": "Community/Population Health",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Physicians Genesis Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "Q408",
    "title": "Opioid Therapy Follow-up Evaluation (Q408)",
    "description": "All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Physicians Genesis Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "Q414",
    "title": "Evaluation or Interview for Risk of Opioid Misuse (Q414)",
    "description": "All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Physicians Genesis Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "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\n\nInverse measure",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "intermediateOutcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRad2",
    "title": "CT Colonography Clinically Significant Extracolonic Findings (Inverse Measure)",
    "description": "Percentage of exams resulting in recommendations for clinical correlation or additional imaging on the basis of the CTC report",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRad23",
    "title": "Lung Cancer Screening Abnormal Interpretation Rate",
    "description": "The percentage of screening lung cancer interpreted\nas 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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRad21",
    "title": "Lung Cancer Screening Cancer Detection Rate (CDR)",
    "description": "The percentage of screenings of lung cancer that\nwere interpreted as positive (Lung-RADS category 3\nor 4) and result in a tissue diagnosis of cancer within\n12 months.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRad22",
    "title": "Lung Cancer Screening Positive Predictive Value (PPV)",
    "description": "The percentage of screenings for lung cancer with\nabnormal interpretation (Lung-RADS 3 or 4) that\nresult in a tissue diagnosis of cancer within 12\nmonths.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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.\n\nInverse measure",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "intermediateOutcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRad28",
    "title": "Rate of early peristomal infection following fluoroscopically guided gastrostomy tube placement",
    "description": "Incidence of peristomal gastrostomy infection occurring within 14 days following initial tube placement\n\nInverse measure",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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\nreplacement within 30 days following initial\nplacement.\n\nInverse measure",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRad18",
    "title": "Report Turnaround Time: CT\n(Inverse Measure)",
    "description": "Mean CT report turnaround time (RTAT)",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRad25",
    "title": "Report Turnaround Time: Mammography",
    "description": "Mean mammography report turnaround time (RTAT).\nInverse measure\nContinuous measure scoring",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRad17",
    "title": "Report Turnaround Time: MRI\n(Inverse Measure)",
    "description": "Mean MRI report turnaround time (RTAT)",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRad19",
    "title": "Report Turnaround Time: PET\n(Inverse Measure)",
    "description": "Mean PET report turnaround time (RTAT)",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRad15",
    "title": "Report Turnaround Time: Radiography (modified)\n(Inverse Measure)",
    "description": "Mean radiography report turnaround time (RTAT).\n(Does not include mammography.)",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRad16",
    "title": "Report Turnaround Time: Ultrasound (Excluding Breast US)\n(Inverse Measure)",
    "description": "Mean Ultrasound report turnaround time (RTAT)",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRad5",
    "title": "Screening Mammography Abnormal Interpretation Rate (Recall Rate)\n(inverse Measure)",
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRad3",
    "title": "Screening Mammography Cancer Detection Rate (CDR)",
    "description": "The fraction of all screening mammograms that are\ninterpreted as positive (abnormal) and have a tissue\ndiagnosis of cancer within 12 months (expressed per\n1000 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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRad7",
    "title": "Screening Mammography Node Negativity Rate",
    "description": "The percentage of invasive cancers detected at\nscreening 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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRad6",
    "title": "Screening Mammography Positive Predictive Value 2 (PPV2 - Biopsy\nRecommended)",
    "description": "The percentage of screening mammograms where\nbiopsy was recommended that have a tissue\ndiagnosis 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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRad27",
    "title": "Uterine artery embolization technique: Documentation of angiographic endpoints and interrogation of ovarian arteries",
    "description": "Documentation of angiographic endpoints of embolization AND the documentation of embolization strategies in the presence of unilateral or bilateral absent uterine arteries.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 documentation 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": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 peri-operative management plan for anticoagulation medications documented in the medical record",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACS18",
    "title": "Patient Frailty Evaluation",
    "description": "Percentage of patients age 80 and older who have been evaluated for frailty prior to an elective operation.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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. An 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. An 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 Foley catheter.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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. A postoperative care plan is established, addressing mobilization, pain management, diet, resumption of preoperative medications, management of drains/catheters/invasive lines, and wound care.\n2. A 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 30 days following surgery.\n4. A 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": "American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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. A 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. A 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, IV lines, etc).",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "Pinc51",
    "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": "American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "American Podiatric Medical Association, Inc. (APMA Registry)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "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.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "U.S. Wound Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "American Society of Nuclear Cardiology ImageGuide",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "American Society of Nuclear Cardiology ImageGuide",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "American Society of Nuclear Cardiology ImageGuide",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASNC4",
    "title": "Utilization of standardized nomenclature and reporting for nuclear cardiology imaging studies",
    "description": "Percentage of stress nuclear Myocardial Perfusion Imaging (MPI) studies performed on patients where standardized nomenclature and reporting was used and the standardized nomenclature was used in the institution’s computer systems.",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Society of Nuclear Cardiology ImageGuide",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASNC13",
    "title": "SPECT-MPI studies meeting appropriate use criteria",
    "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion\n Imaging (MPI) studies performed that are appropriate.",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "efficiency",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Society of Nuclear Cardiology ImageGuide",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASNC14",
    "title": "PET-MPI studies meeting appropriate use criteria",
    "description": "Percentage of Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies\n performed that are appropriate.",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "efficiency",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Society of Nuclear Cardiology ImageGuide",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASNC17",
    "title": "SPECT-MPI studies not Equivocal",
    "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies performed that are not equivocal.",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "efficiency",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Society of Nuclear Cardiology ImageGuide",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASNC18",
    "title": "PET-MPI studies not Equivocal",
    "description": "Percentage of Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies\n performed that are not equivocal.",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "efficiency",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Society of Nuclear Cardiology ImageGuide",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "American Society of Nuclear Cardiology ImageGuide",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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\n Imaging (MPI) studies performed without the use of thallium.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Society of Nuclear Cardiology ImageGuide",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Society of Nuclear Cardiology ImageGuide",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "American Society of Nuclear Cardiology ImageGuide",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "efficiency",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Society of Nuclear Cardiology ImageGuide",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Society of Nuclear Cardiology ImageGuide",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "efficiency",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Society of Nuclear Cardiology ImageGuide",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CDR1",
    "title": "Adequate Off-loading of Diabetic Foot Ulcer at each treatment visit",
    "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": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "U.S. Wound Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "American Society of Plastic Surgeons",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASPS6",
    "title": "Breast Reconstruction: Flap Loss",
    "description": "Percentage of female patients aged 18 years or older who had breast reconstruction via autologous reconstruction (not including latissimus flap) with or without a tissue expander or implant who present with flap loss within 30 days of the primary breast reconstruction procedure.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American Society of Plastic Surgeons",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AUGS2",
    "title": "Preoperative utilization of pessary prior to Pelvic Organ Prolapse surgery",
    "description": "The percentage of patients who have attempted pessary placement or the treatment of pelvic organ prolapse prior to surgical intervention.",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AUGS6",
    "title": "Route of Hysterectomy",
    "description": "Percentage of patients who underwent vaginal hysterectomy.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "intermediateOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQUA5",
    "title": "Benign Prostate Hyperplasia: Do not order creatinine lab for patients",
    "description": "Percentage of patients with NEW diagnosis of BPH who had creatinine lab order placed",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American Urological Association",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQUA6",
    "title": "Benign Prostate Hyperplasia: Do not order upper-tract imaging",
    "description": "Percentage of patients with NEW diagnosis of BPH who had 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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "American Urological Association",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American Urological Association",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQUA8",
    "title": "Hospital re-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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQUA4",
    "title": "Hypogonadism: Testosterone lab ordered/reported 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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQUA11",
    "title": "Prostate Cancer: Patient Report of Sexual function after treatment",
    "description": "Patient report of sexual function 24 months after treatment, adjusting for nerve sparing, age/baseline, RT approach",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "American Urological Association",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQUA10",
    "title": "Prostate Cancer: Patient Report of Urinary function after treatment",
    "description": "Patient report of urinary function 12months after treatment , adjusting for age/baseline",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "American Urological Association",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Efficiency and Cost Reduction",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "American Urological Association",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQUA16",
    "title": "Non-Muscle Invasive Bladder Cancer: Repeat Transurethal Resection of Bladder Tumor (TURBT) for T1 disease",
    "description": "Percentage of patients with T1 disease, that had a second TURBTwithin 6 weeks fo the initial TURBT",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Urological Association",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Americas Hernia Society Quality Collaborative",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Americas Hernia Society Quality Collaborative",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Americas Hernia Society Quality Collaborative",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "hernia",
        "description": "Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Any hernia width (overall rate)"
      },
      {
        "name": "overall",
        "description": "Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of ≤10cm"
      },
      {
        "name": "hernia>10cm",
        "description": "Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of >10cm"
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AHSQC7",
    "title": "Abdominal Wall Reconstruction Preoperative Diabetes Assessment",
    "description": "Percentage of diabetic 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) with hemoglobin A1C assessment within 6 months prior to operation",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Americas Hernia Society Quality Collaborative",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "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": "Americas Hernia Society Quality Collaborative",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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.\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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Americas Hernia Society Quality Collaborative",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "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": "Anesthesia Business Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Anesthesia Business Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 Nauesa and Vomiting risk factors during their pre-anesthetic evaluation",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Business Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Anesthesia Business Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Business Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 and whose pain related functional status stayed the same or improved.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Business Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Business Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Anesthesia Business Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI35",
    "title": "Perioperative Mortality Rate - INVERSE MEASURE",
    "description": "Percentage of patients, regardless of age, who undergo a procedure under anesthesia and who experience mortality under the care of an anesthesia provider prior to anesthesia end time.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ABG4",
    "title": "PACU tracheal intubation Rate",
    "description": "The rate of tracheal intubation in the PACU for all patients who have anesthesia in the operating room/procedure room.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Business Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ABG5",
    "title": "Composite Procedural Safety for All Vascular Access Procedures",
    "description": "Percentage of adults under anesthesia care who experience a serious injury from an attempt at securing vascular access of any type (arterial, central venous, peripheral venous) in the operating room/procedure room or PACU.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Business Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 within 15 minutes of arrival.",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Business Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI48",
    "title": "Anesthesia: Patient Experience Survey",
    "description": "Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care.",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ABG14",
    "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 prior to discharge from PACU",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Business Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ABG15",
    "title": "Dental Injury",
    "description": "Percentage of patients who have general anesthesia and have an unintended change in dental status that is identified prior to PACU discharge",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Business Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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, the rate with which it's use is planned ahead of time for either therapeutic or educational purposes.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Business Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Business Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI49",
    "title": "Adherence to Blood Conservation Guidelines for Cardiac Operations using Cardiopulmonary Bypass (CPB) – Composite",
    "description": "This measure will have a total of five performance rates: one for each of the four selected blood conservation strategies as well as a fifth, overall performance rate. The rates are described below:\n\nRate 1: Lysine Analogues: Percentage of denominator-eligible patients for whom lysine analogues were used\nRate 2: Mini-circuits, RAP, or ultrafiltration: Percentage of denominator-eligible patients for whom mini-circuits, or Retrograde Autologous Priming (RAP) or ultrafiltration were used\nRate 3: Red Cell Salvage using Centrifugation: Percentage of denominator-eligible patients for whom red cell salvage using centrifugation was used\nRate 4: Transfusion Algorithm with Point-of-Care Testing: Percentage of denominator-eligible patients for whom a transfusion algorithm supplemented with point-of-care testing was used\nRate 5: Composite Performance Score: Percentage of denominator-eligible patients for whom a cumulative score of 100% of blood conservation strategies was met",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "lysine",
        "description": "Lysine Analogues: Percentage of denominator-eligible patients for whom lysine analogues were used"
      },
      {
        "name": "mini",
        "description": "Mini-circuits, RAP, or ultrafiltration: Percentage of denominator-eligible patients for whom mini-circuits, or Retrograde Autologous Priming (RAP) or ultrafiltration were used"
      },
      {
        "name": "redcell",
        "description": "Red Cell Salvage using Centrifugation: Percentage of denominator-eligible patients for whom red cell salvage using centrifugation was used"
      },
      {
        "name": "transfusion",
        "description": "Transfusion Algorithm with Point-of-Care Testing: Percentage of denominator-eligible patients for whom a transfusion algorithm supplemented with point-of-care testing was used"
      },
      {
        "name": "overall",
        "description": "Composite Performance Score: Percentage of denominator-eligible patients for whom a cumulative score of 100% of blood conservation strategies was met"
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI50",
    "title": "Application of Lung-Protective Ventilation during General Anesthesia",
    "description": "Percentage of patients, aged 18 years and older, who undergo general anesthesia care that includes an endotracheal tube who had a median exhaled tidal volume less than or equal to 10 mL/kg of predicted-body-weight (PBW) 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)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 (without pre-existing renal failure) 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)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI28",
    "title": "New Corneal Injury Not Diagnosed in the Postanesthesia Care Unit/Recovery Area after Anesthesia Care",
    "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 anesthesia end time.",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI34",
    "title": "Perioperative Cardiac Arrest - INVERSE MEASURE",
    "description": "Percentage of patients, regardless of age, who undergo a procedure under anesthesia and who experience a cardiac arrest under the care of a qualified anesthesia provider prior to anesthesia end time",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI31",
    "title": "Postanesthesia Care Unit (PACU) Re-intubation Rate - INVERSE MEASURE",
    "description": "Percentage of patients, regardless of age, who received general anesthesia for a procedure via endotracheal tube who were extubated in the operating room or the postanesthesia care unit (PACU), and required re-intubation prior to PACU discharge.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "intermediateOutcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI29",
    "title": "Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics)",
    "description": "Percentage of patients aged 3 through 17 years of age, 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 or intraoperatively.",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI32",
    "title": "Procedural Safety for Central Line Placement",
    "description": "Percentage of patients, regardless of age, who underwent a central venous cannulation insertion and did not experience a central line placement injury.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "intermediateOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI37",
    "title": "Surgical Safety Checklist – Applicable Safety Checks Completed Before Induction of Anesthesia",
    "description": "Percentage of patients, regardless of age, who undergo a surgical procedure under general anesthesia who have documentation that all applicable safety checks from the World Health Organization (WHO) Surgical Safety Checklist (or other surgical checklist that includes the applicable safety checks for the specific procedure) were performed before induction of general anesthesia.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI52",
    "title": "Treatment of Hyperglycemia with Insulin",
    "description": "The percentage of patients, aged 18 years and older, who undergo elective inpatient surgery and who have a blood glucose level of > 200 mg/dL and who receive insulin prior to anesthesia end time.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "intermediateOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASPIRE4",
    "title": "Administration of insulin or glucose recheck for patients with hyperglycemia",
    "description": "The percentage of cases with a perioperative glucose >200 mg/dL with administration of insulin or glucose recheck within 90 minutes of original elevated glucose measurement.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASPIRE3",
    "title": "Administration of Neostigmine before Extubation for Cases with Nondepolarizing Neuromuscular Blockade",
    "description": "The percentage of cases with administration of neostigmine, Sugammadex, and/or edrophonium before extubation for cases with non-depolarizing neuromuscular blockade.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASPIRE19",
    "title": "Avoiding acute kidney injury",
    "description": "The 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": "Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASPIRE6",
    "title": "Avoiding excessively high tidal volumes during positive pressure ventilation",
    "description": "The percentage of cases with median tidal volumes less than 10mL/kg.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASPIRE16",
    "title": "Avoiding intraoperative hypotension",
    "description": "The percentage of cases that sustained intraoperative hypotension was avoided.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASPIRE22",
    "title": "Avoiding medication overdose",
    "description": "The percentage of cases where either naloxone or flumazenil was not administered to treat a medication overdose.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASPIRE18",
    "title": "Avoiding myocardial Injury",
    "description": "The percentage of cases without a Troponin I > 1.00 within 72 hours postoperatively.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASPIRE8",
    "title": "Core temperature measurement for all general anesthetics",
    "description": "The percentage of cases with increased risk of hypothermia that the anesthesia provider documented core temperature.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASPIRE2",
    "title": "Train of Four Monitor Documented After Last Dose of Non-depolarizing Neuromuscular Blocker",
    "description": "The percentage of cases with a documented Train of Four after the last dose of a non-depolarizing neuromuscular blocker.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASPIRE13",
    "title": "Transfusion goal of hematocrit less than 30 or hemoglobin less than 10.",
    "description": "The percentage of cases where post-transfusion hematocrit is less than 30%, or hemoglobin less than 10.",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "BNS1",
    "title": "Preoperative notification of risk of developing ischemic optic neuropathy (ION) during prone spine procedures",
    "description": "Percentage of postoperative development of ischemic optic neuropathy (ION) in prone spinal procedures with preoperative notification of risk factors",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Blue Nine Systems, LLC",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 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 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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Cleveland Clinic OME",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Cleveland Clinic OME",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Cleveland Clinic OME",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Cleveland Clinic OME",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Code Technology",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Code Technology",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Code Technology",
    "category": "quality",
    "firstPerformanceYear": 2017,
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    "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Code Technology",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
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    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CODE8",
    "title": "Improved Global Physical Health Outcome Assessment for Cervical Surgery",
    "description": "Percentage of patients aged 18 years and older with cervical surgery who completed baseline and follow-up (patient-reported) PROMIS Global 10 assessments that reported an improvement in global physical health.",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Code Technology",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
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    "isRegistryMeasure": true,
    "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Code Technology",
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    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
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    "isRegistryMeasure": true,
    "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Code Technology",
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    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
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    "metricType": "registrySinglePerformanceRate",
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      "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Code Technology",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
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    "isRegistryMeasure": true,
    "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Code Technology",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
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    "isRegistryMeasure": true,
    "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Code Technology",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Code Technology",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CESQIP6",
    "title": "Evaluation and Integration of anti-coagulant medication prior to surgery",
    "description": "Patients with Documented Evaluation and Integration of Anti-coagulant Medication Prior to Surgery",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by ArborMetrix",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 ArborMetrix",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
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      "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 ArborMetrix",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 ArborMetrix",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 ArborMetrix",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 ArborMetrix",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "patientEngagementExperience",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "Consortium for Universal Health System Metrics",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "patientEngagementExperience",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "Consortium for Universal Health System Metrics",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 schizophrenia or schizoaffective disorder who had at least two prescription drug claims for antipsychotic medications and 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": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "Consortium for Universal Health System Metrics",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "EPREOP4",
    "title": "Short-term Pain Management/Maximum Pain Score",
    "description": "The percentage of patients aged 18 years and older, admitted to the postoperative recovery area after undergoing a surgical procedure that required an anesthetic and had a maximum pain score of <8 out of 10.",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ePreop Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "EPREOP9",
    "title": "Prophylactic Antibiotic Administration",
    "description": "Percentage of patients for whom the administration of an indicated and ordered prophylactic antibiotic is initiated within one hour (or two hours for fluoroquinolone or vancomycin) prior to surgical incision.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ePreop Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "EPREOP14",
    "title": "Dental Injury",
    "description": "Percentage of anesthesia patients who experience chipped, broken, loose, or dislodged teeth following insertion or removal of any of the following airway devices (laryngoscope, video laryngoscopy, supraglottic devices or fiberoptic intubating device).",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "ePreop Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "EPREOP26",
    "title": "Ultrasound Guidance for Central Venous Catheter Placement",
    "description": "Percentage of patients who undergo central venous catheterization for whom ultrasound guidance is used for vessel localization and venipuncture, and documented in the medical record.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ePreop Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "EPREOP27",
    "title": "Ultrasound Guidance for Peripheral Nerve Block",
    "description": "Percentage of patients, aged 18 years and older, who undergo upper or lower extremity  peripheral nerve blockade, and for whom ultrasound guidance is used and documented in the medical record.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ePreop Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "FORCE4",
    "title": "Improvement in Function 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 who had improvement (greater than or equal to 5 point increase from pre-operative functional status measure) in their functional status assessment post-operatively, measured by the PCS and/or KOOS physical function score.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "FORCE-QI",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "FORCE5",
    "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 who had with a KOOS pain assessment score greater than 70 post-operatively, measured by the KOOS pain assessment score.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "FORCE-QI",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "FORCE9",
    "title": "Improvement in Function 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 who had improvement (greater than or equal to 5 point increase from pre-operative functional status measure) in their functional status assessment post-operatively, measured by the PCS and/or HOOS physical function score.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "FORCE-QI",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "FORCE10",
    "title": "Measure 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 who had with a HOOS pain assessment score greater than 70 post-operatively, measured by the HOOS pain assessment score.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "FORCE-QI",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "FORCE17",
    "title": "Functional Status Assessment for Patients with musculoskeletal disease",
    "description": "Percentage of patients 18 years of age and older with musculoskeletal disease who completed baseline and follow-up patient-reported functional status assessments",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "FORCE-QI",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "FORCE18",
    "title": "Pain Status Assessment for Patients with musculoskeletal disease",
    "description": "Percentage of patients 18 years of age and older with musculoskeletal disease who completed baseline and follow-up patient-reported pain status assessments",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "FORCE-QI",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
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    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "FORCE19",
    "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "FORCE-QI",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
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    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "GIQIC15",
    "title": "Appropriate follow-up interval of 3 years recommended based on pathology findings from screening colonoscopy in average-risk patients",
    "description": "Percentage of average-risk patients aged 50 years and older receiving a screening colonoscopy with biopsy or polypectomy and pathology findings of 3-10 adenomas, Advanced Neoplasm (≥ 10 mm, high grade dysplasia, villous component), Sessile serrated polyp ≥ 10 mm OR sessile serrate polyp with dysplasia OR traditional serrated adenoma who had a recommended follow-up interval of 3 years for repeat colonoscopy",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "GI Quality Improvement Consortium (GIQuIC)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "GI Quality Improvement Consortium (GIQuIC)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
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    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "GI Quality Improvement Consortium (GIQuIC)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
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    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NHCR4",
    "title": "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": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "GI Quality Improvement Consortium (GIQuIC)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
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    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "HF1",
    "title": "Knee Arthroscopy for Meniscectomy",
    "description": "The change in a validated knee measure score will be used as a performance measure for surgeons performing knee arthroscopy for meniscectomy. 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 knee arthroscopy for meniscectomy. Isolated Meniscectomy during the reporting period CPT-4 Codes: 29880, 29881. Excluding concurrent with Anterior Cruciate Ligament Reconstruction (29888) and other concomitant procedures. Surgeons who performed a minimum of 25 meniscectomy 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 meniscectomy during the observation period. Patients receiving meniscectomy 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 meniscectomy 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 meniscectomy patients in the denominator. DENOMINATOR: The number of all patients who received meniscectomy 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 meniscectomy patients treated by surgeon. DENOMINATOR: Average predicted 6-month knee measure change score for all meniscectomy 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 meniscectomy 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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
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      "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
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  },
  {
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
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  },
  {
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "HAdv1",
    "title": "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",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "HealthAdvanta",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "HAdv2",
    "title": "Atrial fibrillation (afib) prevention and treatment: Patients with afib who are assessed for lifestyle and disease factors that contribute to uncontrolled afib",
    "description": "Percentage of patients diagnosed with atrial fibrillation (afib) who are assessed for lifestyle and disease factors that contribue to uncontrolled atrial fibrillation at least once in the past 12 months",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "HealthAdvanta",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "M2S16",
    "title": "Absence of unplanned reoperation after major lower extremity 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.\n\n Rationale: Major closed amputations (below and above knee) can be complicated by infection, bleeding or failure to heal, resulting in unplanned reoperation, if the level and conduct of the initial procedure is not appropriate. This outcome measure appropriately identifies proper amputation level selection and proper surgical technique.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "M2S Inc. (Vascular Quality Initiative QCDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "M2S17",
    "title": "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 pseudoaneursm, Thrombosis, Embolization, Perforation, or Dissection (target lesion or other artery) that require admission, or surgical or interventional treatment.\n\n Rationale: Avoiding technical complications is critical to patient safety during peripheral interventional procedures. The complications listed above can result in serious harm, so this outcome measure tracks an important safety issue.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "M2S Inc. (Vascular Quality Initiative QCDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "M2S18",
    "title": "Venous clinical severity score (VCSS) assessment before varicose vein treatment",
    "description": "The percentage of patients undergoing surgical or ablation treatment (radiofrequency, laser, mechanochemical, chemical, or embolic adhesive) of truncal, perforator or cluster veins who have venous clinical severity score (VCSS) of the treated leg(s) assessed prior to treatment.\n Rationale: Pre-treatment assessment using VCSS, which measures 10 clinical signs and symptoms is recommended in practice guidelines to ensure that treatment is not being recommended for patients with minimal venous disease and to allow post-treatment assessment of improvement.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "M2S Inc. (Vascular Quality Initiative QCDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "M2S19",
    "title": "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.\n\n Rationale: Perforator vein treatment has only been shown to benefit patients with venous ulcers or a history of ulcers, but is often applied to patients with less severe disease unnecessarily. This measures documents appropriate patient selection and effective cost reduction.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "M2S Inc. (Vascular Quality Initiative QCDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "M2S1",
    "title": "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,\nSupra-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": "M2S Inc. (Vascular Quality Initiative QCDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "M2S2",
    "title": "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\nafter Infra-Inguinal Bypass for intermittent claudication.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "M2S Inc. (Vascular Quality Initiative QCDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "M2S3",
    "title": "Infra-inguinal bypass for claudication patency assessed at least 9 months following surgery",
    "description": "This measure estimates the frequency of graft patency assessment one year Infra-Inguinal Bypass.",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "M2S Inc. (Vascular Quality Initiative QCDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "M2S4",
    "title": "Amputation-free survival assessed at least 9 months following Supra-Inguinal Bypassfor claudication",
    "description": "This measure estimates freedom from amputation or death at least 9 months after Supra-Inguinal Bypassfor claudication.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "M2S Inc. (Vascular Quality Initiative QCDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "M2S5",
    "title": "Amputation-free survival at assessed at least 9 months following Peripheral Vascular Interventionfor 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": "M2S Inc. (Vascular Quality Initiative QCDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "M2S6",
    "title": "Peripheral Vascular Intervention patency assessed at least 9 months following infrainguinal PVI for claudication",
    "description": "This measure estimates the frequency of patency assessment at least 9 months following infrainguinal Peripheral Vascular Interventionfor claudication.",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "M2S Inc. (Vascular Quality Initiative QCDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "M2S7",
    "title": "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": "M2S Inc. (Vascular Quality Initiative QCDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "M2S8",
    "title": "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": "M2S Inc. (Vascular Quality Initiative QCDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "M2S9",
    "title": "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": "M2S Inc. (Vascular Quality Initiative QCDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "M2S10",
    "title": "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": "M2S Inc. (Vascular Quality Initiative QCDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "M2S11",
    "title": "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": "M2S Inc. (Vascular Quality Initiative QCDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "M2S12",
    "title": "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": "M2S Inc. (Vascular Quality Initiative QCDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "M2S13",
    "title": "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": "M2S Inc. (Vascular Quality Initiative QCDR)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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.\nNote: 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.\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": "Patient Safety",
    "measureType": "patientEngagementExperience",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "SAPE QCDR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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:\n\nBivarus 16: My Doctor Listened To Me\nBivarus 17: My Doctor Made Me Feel Comfortable about 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 Caregiver-Centered Experience and Outcomes/Communication and Care Coordination",
    "measureType": "patientEngagementExperience",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "SAPE QCDR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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.\n\n 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.\n\n Items:\n\n Bivarus 7: Coordination of Care Among Physicians And Nurses\n Bivarus 9: I Was Told How to Arrange an Appointment for Follow-Up Care\n Bivarus 11: The Doctor Provided Follow-Up Care Instructions in A Way I Could Understand\n Bivarus 12: I Was Involved In Developing My Care or Follow-Up Plan",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "patientEngagementExperience",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "SAPE QCDR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "BIVARUS30",
    "title": "Patient Reported Pain Treatment Effectiveness",
    "description": "This measure is a patient reported outcome measure.\n\n This measure is derived from responses on 1 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 outcome measure.\n\n 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.\n\n Item:\n\n Bivarus 13: My Pain Was Treated Effectively",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "SAPE QCDR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "BIVARUS31",
    "title": "Patient Reported Communication and Care Coordination",
    "description": "This measure is a patient reported outcome measure.\n\n This measure is derived from responses on 1 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 outcome measure.\n\n 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.\n\n Item:\n\n Bivarus 20: I Understood What the Physician Told Me",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "SAPE QCDR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MOA 1",
    "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 Patient 360",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "MOA 2",
    "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": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "Maine Osteopathic Association in Collaboration with Patient 360",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MOA 7",
    "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, etc.).\n\nMeasure 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 Patient 360",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MOA 13",
    "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\nMeasure 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 Patient 360",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MOA 14",
    "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\n Measure 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 Patient 360",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MOA 15",
    "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.\n\nMeasure 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 Patient 360",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MOA 12",
    "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\nProviders 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\nMeasure 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": "Efficiency and Cost Reduction",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "Maine Osteopathic Association in Collaboration with Patient 360",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MeHC1",
    "title": "Hemoglobin A1c Test for Pediatric Patients",
    "description": "Percentage of patients 5-17 years of age with diabetes with a HbA1c test during the measurement period",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Massachusetts eHealth Collaborative",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ECPR39",
    "title": "Avoid Head CT for Patients with Uncomplicated Syncope",
    "description": "Percentage of Adult Syncope Patients Who Did Not Receive a Head CT Scan Ordered by the Provider",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MedAmerica-E-CPR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ECPR43",
    "title": "Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or Bleeding",
    "description": "multiple performance rates include:\nRate 1: In Emergency Department (ED), Percentage of Patients Aged 18 Years and Older with a Diagnosis of Chest Pain Where the Provider Ordered Coagulation Studies (PT, PTT, or INR)\nRate 2: In Urgent Care (UC), Percentage of Patients Aged 18 Years and Older with a Diagnosis of Chest Pain Where the Provider Ordered Coagulation Studies (PT, PTT, or INR)",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "MedAmerica-E-CPR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "overall",
        "description": "In Emergency Department (ED), Percentage of Patients Aged 18 Years and Older with a Diagnosis of Chest Pain Where the Provider Ordered Coagulation Studies (PT, PTT, or INR)"
      },
      {
        "name": "urgentcare",
        "description": "In Urgent Care (UC), Percentage of Patients Aged 18 Years and Older with a Diagnosis of Chest Pain Where the Provider Ordered Coagulation Studies (PT, PTT, or INR)"
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ECPR2",
    "title": "Door to Diagnostic Evaluation by a Provider – Emergency Department (ED) Patients",
    "description": "Risk-adjusted Mean Time from ED Arrival to Provider Contact for ED Patients Evaluated by the Eligible Professional; multiple performance rates include:\n• Time - Overall\n• Time - Adult (≥ 18 years of age)\n• Time - Pediatric (< 18 years of age)",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "MedAmerica-E-CPR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ECPR44",
    "title": "Door to Diagnostic Evaluation by a Provider – Urgent Care Patients",
    "description": "Risk-adjusted Mean Time from Urgent Care Clinic (UCC) Arrival to Provider Contact for Urgent Care Patients Evaluated by the Eligible Professional; multiple performance rates include:\n• Time - Overall\n• Time - Adult (≥ 18 years of age)\n• Time - Pediatric (< 18 years of age)",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "MedAmerica-E-CPR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ECPR40",
    "title": "Initiation of the Initial Sepsis Bundle",
    "description": "Percentage of Adult Emergency Department Patients Diagnosed with Severe Sepsis or Septic Shock That Have Initiation of the Initial Sepsis Bundle",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MedAmerica-E-CPR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ECPR6",
    "title": "Mean Time from Emergency Department (ED) Arrival to ED Departure for Discharged Higher Acuity ED Patients",
    "description": "Risk-adjusted Mean Time from ED Arrival to Time of Departure from the ED for Higher Acuity Patients Discharged from the ED",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "MedAmerica-E-CPR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ECPR5",
    "title": "Mean Time from Emergency Department (ED) Arrival to ED Departure for Discharged Lower Acuity ED Patients",
    "description": "Risk-adjusted Mean Time from ED Arrival to Time of Departure from the ED for Lower Acuity Patients Discharged from the ED",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "MedAmerica-E-CPR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ECPR42",
    "title": "Restrictive Use of Blood Transfusions",
    "description": "Percentage of Adult Patients with a Diagnosis of Anemia Who Did Not Receive a Blood Transfusion When Hgb > 8g/dL (Restrictive Transfusion Guidelines)",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MedAmerica-E-CPR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ECPR41",
    "title": "Rh Status Evaluation and Treatment of Pregnant Women at Risk of Fetal Blood Exposure",
    "description": "Percentage of Women Aged 14-50 Years at Risk of Fetal Blood Exposure Who Had Their Rh Status Evaluated in the Emergency Department (ED) and Received Rh-Immunoglobulin (Rhogam) if Rh-negative",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MedAmerica-E-CPR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ECPR11",
    "title": "Three Day All Cause Return ED Visit Rate – All Patients",
    "description": "Risk-adjusted Percentage of the Eligible Professional’s ED Discharged Patients that Returned to the Same Emergency Department (ED) within Three Calendar Days of Prior ED Visit Date of Service; multiple performance rates include:\n• Time - Overall\n• Time - Adult (≥ 18 years of age)\n• Time - Pediatric (< 18 years of age)",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "MedAmerica-E-CPR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ECPR38",
    "title": "Three Day All Cause Return ED Visit Rate with Admission on Re-Visit",
    "description": "Risk-Adjusted Percentage of the Eligible Professional’s ED Discharged Patients that Returned to the Same Emergency Department (ED) within Three Calendar Days of Prior ED Visit Date of Service with Admission on Re-Visit; multiple performance rates include:\n• Time - Overall\n• Time - Adult (≥ 18 years of age)\n• Time - Pediatric (< 18 years of age)",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "MedAmerica-E-CPR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "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; multiple performance rates include:\n• Readmission Rate – All Discharged Patients\n• Readmission Rate – Discharged Pneumonia Patients\n• Readmission Rate – Discharged CHF Patients\n• Readmission Rate – Discharged COPD Patients",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "MedAmerica-H-CPR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "HCPR4",
    "title": "Mean Length of Stay for Inpatients – CHF",
    "description": "Weighted, 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": "MedAmerica-H-CPR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "HCPR5",
    "title": "Mean Length of Stay for Inpatients – COPD",
    "description": "Weighted, 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": "MedAmerica-H-CPR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "HCPR3",
    "title": "Mean Length of Stay for Inpatients – Pneumonia",
    "description": "Weighted, Risk-Adjusted Mean LOS for All Inpatients Diagnosed with Pneumonia",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "MedAmerica-H-CPR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "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": "MedAmerica-H-CPR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "MedAmerica-H-CPR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "MedAmerica-H-CPR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "MedAmerica-H-CPR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "MedAmerica-H-CPR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI30",
    "title": "Anesthesia Safety",
    "description": "Percentage of patients, regardless of age, who undergo a procedure under anesthesia without the occurrence of a major adverse event prior to completion of anesthesia care.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Medaxion",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MA1",
    "title": "Case Delay",
    "description": "Percentage of cases marked as delayed from scheduled start with a reason indicated",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "efficiency",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Medaxion",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MA2",
    "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 in the post-anesthesia care unit/recovery area.",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Medaxion",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MIRAMED3",
    "title": "Dental Injury",
    "description": "Percentage of patients experiencing dental trauma due to intubation during an anesthetic\nprocedure.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "intermediateOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MiraMed",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MICS1",
    "title": "General Health Postoperative Improvement",
    "description": "Instructions: 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.\n\nOverall percentage: The overall percentage of patients that improve beyond a minimum threshold of 5% from preoperatively to 4 weeks postoperatively; 7% from preoperatively to 6 weeks postoperatively; 10% from preoperatively to 3 months postoperatively; and 15% from preoperatively to 6 months postoperatively.\n\nRate 1: Change in the calculated score of a validated general health patient reported outcome survey from before to after surgery.\nRate 2: The overall percentage of patients that improve their general health scores beyond a minimum threshold for each postoperative interval.",
    "nationalQualityStrategyDomain": "Community/Population Health",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MedTrak, Inc. CareSense QCDR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MICS2",
    "title": "Surgery Specific Postoperative Improvement in Pain Levels",
    "description": "Instructions: 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.\n\nOverall percentage: The overall percentage of patients that improve beyond a minimum threshold of 10% from preoperatively to 4 weeks postoperatively; 15% from preoperatively to 6 weeks postoperatively; 20% from preoperatively to 3 months postoperatively; and 25% from preoperatively to 6 months postoperatively.\n\nRate 1: Change in the calculated pain scores of a validated surgery specific patient reported outcome survey from before to after surgery.\nRate 2: The overall percentage of patients that improve their pain scores beyond a minimum threshold for each postoperative interval.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MedTrak, Inc. CareSense QCDR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MICS3",
    "title": "Surgery Specific Postoperative Improvement in Function Levels",
    "description": "Instructions: 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.\n\nThe overall percentage of patients that improve beyond a minimum threshold of 10% from preoperatively to 4 weeks postoperatively; 15% from preoperatively to 6 weeks postoperatively; 20% from preoperatively to 3 months postoperatively; and 25% from preoperatively to 6 months postoperatively.\n\nRate 1: Change in the calculated function scores of a validated surgery specific patient reported outcome survey from before to after surgery.\nRate 2: The overall percentage of patients that improve their function scores beyond a minimum threshold for each postoperative interval.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MedTrak, Inc. CareSense QCDR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MEX1",
    "title": "Heel Pain Treatment Outcomes for Adults",
    "description": "DESCRIPTION:\n Percentage of patients aged 18 years and older with a diagnosis of heel pain who had two or more encounters in the past year\n\n INSTRUCTIONS:\n This measure is to be reported each visit for patients with heel pain seen during the reporting period. Documentation of pain level in patients with heel pain to evaluate change in reported heel pain over time with treatment of heel pain. The Pain Scale should be reported using the standard 1-10 Pain Scale.\n\n Measure Reporting via Registry:\n ICD-10-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure’s denominator. The listed numerator options are used to report the numerator of the measure.\n Patients who are not able to communicate a pain level or have neuropathy are exclusions for this measure.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MedXpress Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MEX2",
    "title": "Heel Pain Treatment Outcomes for Pediatric Patients",
    "description": "DESCRIPTION:\nPercentage of patients aged 6 to 18 years with a diagnosis of heel pain who experience a decrease in heel pain.\n\nINSTRUCTIONS:\n This measure is to be reported each visit for patients in the cohort with heel pain seen during the reporting period. Documentation of pain level in patients with heel pain to evaluate change in reported heel pain over time with treatment of heel pain. The Pain Scale should be reported using the standard 1-10 Pain Scale.\n\n Measure Reporting via Registry:\n ICD-10-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure’s denominator. The listed numerator options are used to report the numerator of the measure.\n Patients who are not able to communicate a pain level or have neuropathy are exclusions for this measure.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MedXpress Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MEX3",
    "title": "Identification of Flat Foot in Pediatric Patients",
    "description": "DESCRIPTION:\nPercentage 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\n\nINSTRUCTIONS:\nThis measure is to be reported a minimum of once per reporting period for eligible patients with a diagnosis of flat foot seen during the reporting period. Documentation of flat foot in patients to have appropriate foot and ankle care to ensure the treatment is appropriate based upon the age of the patient.\n\n Measure Reporting via Registry:\n ICD-10-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure’s denominator. The listed numerator options are used to report the numerator of the measure.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MedXpress Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MBSAQIP1",
    "title": "Risk standardized rate of patients who experienced a postoperative complication within 30 days",
    "description": "Risk standardized rate of patients who experienced a postoperative complication within 30 days\n following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation,\n performed as a primary (not revisional) procedure.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MBSAQIP2",
    "title": "Risk standardized rate of patients who experienced an unplanned readmission within 30 days",
    "description": "Risk standardized rate of patients who experienced an unplanned readmission (likely related to the initial operation) within 30 days following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary (not revisional) procedure.",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MBSAQIP3",
    "title": "Risk standardized rate of patients who experienced a reoperation within 30 days",
    "description": "Risk standardized rate of patients who experienced a reoperation (likely related to the initial operation) within 30 days following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary (not revisional) procedure.",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MBSAQIP4",
    "title": "Risk standardized rate of patients who experienced an anastomotic/staple line leak within 30 days",
    "description": "Risk standardized rate of patients who experienced an anastomotic/staple line leak within 30 days following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary (not revisional) procedure.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MBSAQIP6",
    "title": "Risk standardized rate of patients who experienced a postoperative surgical site infection (SSI) within 30 days",
    "description": "Risk standardized rate of patients who experienced a postoperative surgical site infection (SSI) (superficial incisional, deep incisional, or organ/space SSI) within 30 days following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary (not revisional) procedure.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MBSAQIP7",
    "title": "Risk standardized rate of patients who experienced postoperative nausea, vomiting or fluid/electrolyte/nutritional depletion within 30 days",
    "description": "Risk standardized rate of patients who experienced postoperative nausea, vomiting or fluid/electrolyte/nutritional depletion within 30 days following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary (not revisional) procedure.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MBSAQIP8",
    "title": "Risk standardized rate of patients who experienced extended length of stay (> 7 days)",
    "description": "Risk standardized rate of patients who experienced extended length of stay (> 7 days) following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary (not revisional) procedure.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MSSIC2",
    "title": "Assessment of back or neck pain",
    "description": "The measure reflects the percent of patients receiving spine surgery for whom a formal assessment of back or neck pain (depending on the location of the spine probem) was done prior to surgery using a standard 0-10 numeric pain rating scale.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Michigan Spine Surgery Improvement Collaborative",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MSSIC3",
    "title": "Assessment of leg or arm pain",
    "description": "The measure reflects the percent of patients receiving spine surgery for whom a formal assessment of leg or arm pain (depending on the location of the spine problem) was done prior to surgery using a standard 0-10 numeric pain rating scale.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Michigan Spine Surgery Improvement Collaborative",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MSSIC4",
    "title": "Assessment of pain-related disability (ODI/NDI)",
    "description": "The measure reflects the percent of patients receiving cervical spine surgery for whom a formal assessment pain-related disability was done, using either the Oswestry Disability Index (lumbar spine patients) or the Neck Disability Index (cervical spine patients).",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Michigan Spine Surgery Improvement Collaborative",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MSSIC5",
    "title": "Follow-up (90 day) assessment of myelopathy (cervical only)",
    "description": "The measure reflects the percent of patients receiving spine surgery who were formally assessed for myelopathy 90 days after surgery, using the mJOA scale. Ideally, this rate would be 100%. Surgical practices in MSSIC have rates generally ranging from 40% at the low end to 85% at the high end.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Michigan Spine Surgery Improvement Collaborative",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MSSIC8",
    "title": "Percent of patients achieving MCID for back or neck pain",
    "description": "The measures 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": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "Michigan Spine Surgery Improvement Collaborative",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MSSIC9",
    "title": "Percent of patients achieving MCID for leg or arm pain",
    "description": "The measures 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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "Michigan Spine Surgery Improvement Collaborative",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MSSIC10",
    "title": "Percent of patients achieving MCID for pain-related disability (ODI/NDI)",
    "description": "The measures 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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "Michigan Spine Surgery Improvement Collaborative",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MSSIC6",
    "title": "Percent same-day ambulation",
    "description": "The measures 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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Michigan Spine Surgery Improvement Collaborative",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MSSIC7",
    "title": "Rate of use of Pre-op skin preparation/wash",
    "description": "The measures 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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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\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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MSSIC15",
    "title": "Unplanned Return to OR Rate",
    "description": "The measure reflects the percent of patients receiving spine surgery who had an unplanned return to the operating room, either during the index admission (or equivalent outpatient stay for outpatient procedures) or during the 90-day period post-discharge. Unplanned return to the OR reflects a quality problem of some kind, and rates vary significantly from surgeon to surgeon and from hospital to hospital.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Michigan Spine Surgery Improvement Collaborative",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MUSIC6",
    "title": "Prostate Cancer: Unplanned Hospital Readmission After Radical Prostatectomy",
    "description": "Percentage of patients aged 30 years and older who had an unplanned hospital readmission within 30 days of principal procedure",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MUSIC2",
    "title": "Prostate Biopsy: Unplanned Hospital Admission within 30 Days of TRUS Biopsy",
    "description": "Percentage of biopsies where patients aged 30 years and older had an unplanned hospital admission within 30 days of biopsy",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MIRAMED5",
    "title": "Adult PACU Pain Management",
    "description": "The rate of all patients, 18 or older, transferred to the postanesthesia care unit (PACU) after care under an anesthesia provider with a maximum pain score greater than 7/10 within 1 hour of arrival to the PACU.",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MiraMed",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MIRAMED9",
    "title": "Case Delay Rate",
    "description": "Percentage of scheduled anesthesia cases or pain procedures which are delayed greater than 15 minutes after the scheduled start time due to the surgeon being late, anesthesia staff late, or room not ready.",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MiraMed",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MIRAMED7",
    "title": "New Corneal Injury Not Diagnosed in the Postanesthesia Care Unit/Recovery Area after Anesthesia Care",
    "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 anesthesia end time.**",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MiraMed",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ABG12",
    "title": "Patient Experience Survey",
    "description": "Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care.",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MiraMed",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MIRAMED4",
    "title": "Perioperative Mortality Rate",
    "description": "Percentage of patients, regardless of age, who undergo a procedure* under anesthesia and who experience mortality under the care of an anesthesia provider prior to anesthesia end time.**",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "MiraMed",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "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": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MiraMed",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MIRAMED13",
    "title": "Screening and patient education for high risk patients meeting guidelines for Abdominal Aortic Ultrasound Screening",
    "description": "Percentage of patients receiving an abdominal aortic aneurysm screening risk assessment via a patient portal, and if meeting established criteria, notified of need for follow-up from the provider",
    "nationalQualityStrategyDomain": "Community/Population Health",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MiraMed",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MIRAMED14",
    "title": "Screening and patient education for high risk patients meeting guidelines for Breast Cancer screening with MRI",
    "description": "Percentage of patients received a breast cancer screening risk assessment via a patient portal, and if meeting established criteria, notified of need for follow-up from the provider.",
    "nationalQualityStrategyDomain": "Community/Population Health",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MiraMed",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MIRAMED12",
    "title": "Screening and patient education for high risk patients meeting guidelines for Lung Cancer Screening with CT",
    "description": "Percentage of patients receiving a lung cancer screening risk assessment via a patient portal, and if meeting established criteria, notified of need for follow-up from the provider",
    "nationalQualityStrategyDomain": "Community/Population Health",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MiraMed",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MIRAMED15",
    "title": "Screening and patient education for high risk patients meeting guidelines for osteoporosis screening",
    "description": "Percentage of patients received an osteoporosis risk assessment via a patient portal, and if\nmeeting established criteria, notified of need for follow-up from the provider.",
    "nationalQualityStrategyDomain": "Community/Population Health",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MiraMed",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MIRAMED11",
    "title": "Screening and patient education for patients meeting guidelines for Colorectal Cancer screening",
    "description": "Percentage of patients receiving a colon cancer screening risk assessment via a patient portal, and if meeting established criteria, notified of need for follow up from the provider.",
    "nationalQualityStrategyDomain": "Community/Population Health",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MiraMed",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MNCM1",
    "title": "Optimal Diabetes Care",
    "description": "The percentage of patients 18‐75 years of age who had a diagnosis of type 1 or type 2 diabetes and whose diabetes  was optimally managed during the measurement period as defined by achieving ALL of the following:\n>HbA1c less than 8.0 mg/dL                                                                                                                                                         > Blood Pressure less than 140/90 mmHg                                                                                                                              >On a statin medication, unless allowed contraindications or exceptions are present\n>Non‐tobacco user                                                                                                                                                            >Patient with ischemic vascular disease is on daily aspirin or anti‐platelets, unless allowed contraindications or  exceptions are present",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MN Community Measurement",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MNCM2",
    "title": "Optimal Vascular Care",
    "description": "The percentage of patients 18-75 years of age who had a diagnosis of ischemic vascular disease (IVD) and whose IVD was optimally managed during the measurement period as defined by achieving ALL of the following:\n* Blood Pressure less than 140/90 mmHg\n* On a statin medication, unless allowed contraindications or exceptions are present\n* Non-tobacco user\n*On daily aspirin or anti-platelets, unless allowed contraindications or exceptions are present",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MN Community Measurement",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MNCM3",
    "title": "Optimal Asthma Control",
    "description": "Rate 1: The percentage of pediatric (5-17 years of age) patients who had a diagnosis of asthma and whose asthma was optimally controlled during the measurement period as defined by achieving BOTH of the following:\n•Asthma well-controlled as defined by the most recent asthma control tool result available during the measurement period\n•Patient not at elevated risk of exacerbation as defined by less than two emergency department visits and/or hospitalizations due to asthma in the last 12 months\n\nRate 2: The percentage of adult (18-50 years of age) patients who had a diagnosis of asthma and whose asthma was optimally controlled during the measurement period as defined by achieving BOTH of the following:\n•Asthma well-controlled as defined by the most recent asthma control tool result available during the measurement period\n•Patient not at elevated risk of exacerbation as defined by less than two emergency department visits and/or hospitalizations due to asthma in the last 12 months",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MN Community Measurement",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "weightedAverage",
    "strata": [
      {
        "name": "pediatric",
        "description": "The percentage of pediatric (5-17 years of age) patients who had a diagnosis of asthma and whose asthma was optimally controlled during the measurement period as defined by achieving BOTH of the following:\n•Asthma well-controlled as defined by the most recent asthma control tool result available during the measurement period\n•Patient not at elevated risk of exacerbation as defined by less than two emergency department visits and/or hospitalizations due to asthma in the last 12 months"
      },
      {
        "name": "adult",
        "description": "The percentage of adult (18-50 years of age) patients who had a diagnosis of asthma and whose asthma was optimally controlled during the measurement period as defined by achieving BOTH of the following:\n•Asthma well-controlled as defined by the most recent asthma control tool result available during the measurement period\n•Patient not at elevated risk of exacerbation as defined by less than two emergency department visits and/or hospitalizations due to asthma in the last 12 months"
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MNCM4",
    "title": "Diabetes Hemoglobin A1c Poor Control (>9.0%)",
    "description": "The percentage of patients 18-75 years of age who had a diagnosis of type 1 or type 2 diabetes and whose A1c (HbA1c) was in poor control (> 9.0%)\n*HbA1c greater than 9.0 mg/dL",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "MN Community Measurement",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MNCM5",
    "title": "Ischemic (IVD): Use of Aspirin or Another Antiplatelet",
    "description": "The percentage of patients 18-75 years of age who had a diagnosis of ischemic vascular disease (IVD) and are on daily aspirin or anti-platelets, unless allowed contraindications or exceptions are present.\n\nOn daily aspirin or anti-platelets, unless allowed contraindications or exceptions are present",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MN Community Measurement",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MSN6",
    "title": "Report Turnaround Time: Facility CT",
    "description": "Mean CT report turnaround time (RTAT).",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "MSN Healthcare Solutions, LLC",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MSN11",
    "title": "Report Turnaround Time: Non-Facility CT",
    "description": "Mean CT report turnaround time (RTAT).",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "MSN Healthcare Solutions, LLC",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MSN5",
    "title": "Report Turnaround Time: Facility MRI",
    "description": "Mean MRI report turnaround time (RTAT).",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "MSN Healthcare Solutions, LLC",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MSN10",
    "title": "Report Turnaround Time: Non-Facility MRI",
    "description": "Mean MRI report turnaround time (RTAT).",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "MSN Healthcare Solutions, LLC",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MSN7",
    "title": "Report Turnaround Time: Facility PET",
    "description": "Mean PET report turnaround time (RTAT).",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "MSN Healthcare Solutions, LLC",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MSN12",
    "title": "Report Turnaround Time: Non-Facility PET",
    "description": "Mean PET report turnaround time (RTAT).",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "MSN Healthcare Solutions, LLC",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MSN8",
    "title": "Report Turnaround Time: Non-Facility Radiography (Excluding Mammography)",
    "description": "Mean radiography report turnaround time (RTAT).\n      (Does not include mammography.)",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "MSN Healthcare Solutions, LLC",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MSN3",
    "title": "Report Turnaround Time: Facility Radiography (Excluding Mammography)",
    "description": "Mean radiography report turnaround time (RTAT).\n (Does not include mammography.)",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "MSN Healthcare Solutions, LLC",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MSN4",
    "title": "Report Turnaround Time: Facility Ultrasound (Excluding Breast US)",
    "description": "Mean Ultrasound turnaround time (RTAT)",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "MSN Healthcare Solutions, LLC",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MSN9",
    "title": "Report Turnaround Time: Non-Facility Ultrasound (Excluding Breast US)",
    "description": "Mean Ultrasound turnaround time (RTAT)",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "MSN Healthcare Solutions, LLC",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MHAN1",
    "title": "Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate",
    "description": "Admissions with a principal diagnosis of chronic obstructive pulmonary disease (COPD)\nor asthma per 1,000 population, ages 40 years and older. Excludes obstetric admissions\nand transfers from other institutions.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "MyHealth Access Network",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MHAN2",
    "title": "Heart Failure Admission Rate",
    "description": "Admissions with a principal diagnosis of heart failure per 100,000 population, ages 18 years and older. Excludes cardiac procedure admissions, obstetric admissions, and transfers from other institutions.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "MyHealth Access Network",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "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": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "MyHealth Access Network",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": true,
    "isRiskAdjusted": false,
    "primarySteward": "National Home Based Primary Care and Palliative Care Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "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 and Palliative Care Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "National Home Based Primary Care and Palliative Care Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "National Home Based Primary Care and Palliative Care Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "NHBPC3",
    "title": "Depression Symptom Assessment 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 the presence of depression symptoms at enrollment and annually.",
    "nationalQualityStrategyDomain": "Community/Population Health",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "National Home Based Primary Care and Palliative Care Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NHBPC5",
    "title": "Depression Treatment Plan for Home-Based Primary Care and Palliative Care Patients Who Screen Positive for Depression",
    "description": "Percentage of actively enrolled home-based primary care and palliative care patients who screen positive for depression symptoms and have a treatment plan** for depression.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "National Home Based Primary Care and Palliative Care Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 and Palliative Care Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NHBPC11",
    "title": "Medication Reconciliation Within 2 Weeks of Hospital Discharge of Home-Based Primary Care and Palliative Care Patients",
    "description": "Percentage of hospitalizations in which actively enrolled home-based primary care and palliative care patients are discharged home and medications were reconciled in the practice medical record within 2 weeks of hospital discharge.",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "National Home Based Primary Care and Palliative Care Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NHBPC4",
    "title": "Pain Screen for Home-Based Primary Care and Palliative Care Patients",
    "description": "Percentage of home-based primary care and palliative care visits at which a patient was screened for the presence of pain.",
    "nationalQualityStrategyDomain": "Community/Population Health",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "National Home Based Primary Care and Palliative Care Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "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": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "National Home Based Primary Care and Palliative Care Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "National Home Based Primary Care and Palliative Care Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 and Palliative Care Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 and Palliative Care Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NOF6",
    "title": "Hip Fracture Mortality Rate (IQI 19)",
    "description": "In-hospital deaths per 1,000 hospital discharges with hip fracture as a principal diagnosis for patients ages 65 years and older. Excludes periprosthetic fracture discharges, obstetric discharges, and transfers to another hospital.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "National Osteoporosis Foundation and National Bone Health Alliance",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "This measure is used to assess the 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": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "National Osteoporosis Foundation and National Bone Health Alliance",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "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": "National Osteoporosis Foundation and National Bone Health Alliance",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "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": "NeuroPoint Alliance Quality Outcomes Database",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NPA7",
    "title": "Complication Following Spine-Related Procedure",
    "description": "Proportion of patients undergoing spine-related procedures who have a complication (specifically, deep venous thrombosis [DVT], pulmonary embolism [PE], myocardial infarction [MI], stroke, urinary tract infection [UTI], or unexpected new neurological deficit) in the 30-day post-procedure period. Modification of NQF #0705.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "NeuroPoint Alliance Quality Outcomes Database",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NPA9",
    "title": "Referral for Post-Acute Care Rehabilitation Following Spine Procedure",
    "description": "Percentage of patients undergoing spine procedure who are prescribed physical therapy and clinician followed up with patient to confirm whether the appointment was made in the 3-month period following the index procedure",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "NeuroPoint Alliance Quality Outcomes Database",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "NeuroPoint Alliance Quality Outcomes Database",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "NeuroPoint Alliance Quality Outcomes Database",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "NeuroPoint Alliance Quality Outcomes Database",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "NeuroPoint Alliance Quality Outcomes Database",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "NeuroPoint Alliance Quality Outcomes Database",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "NeuroPoint Alliance Quality Outcomes Database",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "NeuroPoint Alliance Quality Outcomes Database",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "NeuroPoint Alliance Quality Outcomes Database",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "NeuroPoint Alliance Quality Outcomes Database",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NPA22",
    "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 and documentation of follow-up plan.",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "NeuroPoint Alliance Quality Outcomes Database",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "NeuroPoint Alliance Quality Outcomes Database",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in quality of life status after Follow-up/Patient population with Follow-up.",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "NeuroPoint Alliance Quality Outcomes Database",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "NeuroPoint Alliance Quality Outcomes Database",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "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": "NeuroPoint Alliance, - AAPM&R-AANS's Spine Quality Outcomes Database (SQOD)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "NeuroPoint Alliance, - AAPM&R-AANS's Spine Quality Outcomes Database (SQOD)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "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 with at least 10% improvement in the functional status from the baseline.  This measure will be calculated using two performance rates.  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 functional status (at least 10% improvement) from the baseline.",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "NeuroPoint Alliance, - AAPM&R-AANS's Spine Quality Outcomes Database (SQOD)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 functional status (at least 10% improvement) from the baseline."
      }
    ],
    "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 documentation of decreased narcotic use/requirements at 2 +/-1 months following initial assessment and therapy (ies) for treatment of spine-related pain symptoms with an improvement in pain status from the baseline and documentation of follow-up plan. This measure will be calculated using two performance rates.  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 pain status from the baseline.\nThus Rate 2 =< Rate 1\nOverall Rate = Rate 1",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "NeuroPoint Alliance, - AAPM&R-AANS's Spine Quality Outcomes Database (SQOD)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "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": "NeuroPoint Alliance, - AAPM&R-AANS's Spine Quality Outcomes Database (SQOD)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "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 with an improvement in the quality of life status from the baseline. This measure will be calculated using two performance rates.  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 Quality of life status from the baseline",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "NeuroPoint Alliance, - AAPM&R-AANS's Spine Quality Outcomes Database (SQOD)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 Quality of life status from the 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 satisfaction with care assessment prior to the treatment and at 2 +/- 1 month follow-up (patient-reported) satisfaction with care assessment with an improvement in the satisfaction with care status from the baseline. This measure will be calculated using two performance rates.  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 satisfaction with care status from the baseline",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "NeuroPoint Alliance, - AAPM&R-AANS's Spine Quality Outcomes Database (SQOD)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 satisfaction with care status from the baseline"
      }
    ],
    "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  with an improvement in the pain status from the baseline and documentation of follow-up plan. This measure will be calculated using two performance rates.  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 the pain status from the baseline",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "NeuroPoint Alliance, - AAPM&R-AANS's Spine Quality Outcomes Database (SQOD)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 the pain status from the baseline"
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NHCR5",
    "title": "Colonoscopy: 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": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "New Hampshire Colonoscopy Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NJIISMD7",
    "title": "Critical test: Aortic Dissection",
    "description": "Adherence to Critical Test Protocol: Aortic Dissection.",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "New Jersey Innovation Institute",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NJIISMD6",
    "title": "Critical test: Intracranial Hemorrhage",
    "description": "Adherence to Critical Test Protocol: Intracranial Hemorrhage.",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "New Jersey Innovation Institute",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NJIISMD4",
    "title": "Critical test: OR Foreign Body",
    "description": "Adherence to Critical Test Protocol: OR Foreign Body.",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "New Jersey Innovation Institute",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NJIISMD5",
    "title": "Critical test: Stroke",
    "description": "Adherence to Critical Test Protocol: Stroke.",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "New Jersey Innovation Institute",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NJIISMD22",
    "title": "Critical Finding: 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": "New Jersey Innovation Institute",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "New Jersey Innovation Institute",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NJIISMD19",
    "title": "Critical Finding: 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": "New Jersey Innovation Institute",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "New Jersey Innovation Institute",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NJIISMD20",
    "title": "Critical Finding: 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": "New Jersey Innovation Institute",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "New Jersey Innovation Institute",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "New Jersey Innovation Institute",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "New Jersey Innovation Institute",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "New Jersey Innovation Institute",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NJIISMD21",
    "title": "Critical Finding: Positive bleeding scan",
    "description": "Efficiency of reporting Critical Result: Positive Bleeding Scan",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "New Jersey Innovation Institute",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "New Jersey Innovation Institute",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "New Jersey Innovation Institute",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NJIISMD14",
    "title": "Critical Result Protocol",
    "description": "Timeliness of notification in cases of Critical Results",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "New Jersey Innovation Institute",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "New Jersey Innovation Institute",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NJIISMD16",
    "title": "Unexpected Result Protocol",
    "description": "Timeliness of notification in cases of Unexpected Results",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "New Jersey Innovation Institute",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NJIISMD15",
    "title": "Urgent Result Protocol",
    "description": "Timeliness of notification in cases of Urgent Results",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "New Jersey Innovation Institute",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NJIISMD13",
    "title": "Critical Test Protocol",
    "description": "Timeliness of procedure performance, interpretation and report delivery for diagnostic tests ordered as Critical Tests.",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "New Jersey Innovation Institute",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NNEPTN1",
    "title": "Substance Use Screening",
    "description": "This measure produces two rates of substance use screening:\nRate 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.\nRate 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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NNEPTN3",
    "title": "Transforming Clinical Practice Initiative Common Measure Name: TCPI 01: 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:\n 1. Patient health concerns, life and health goals, behavioral/mental health , coping mechanisms, and self-management plans determined by:\n a. Patient communication\n b. Health professional assessments;\n 2. Identify gaps in the achievement of health and life plan;\n 3. Health status evaluations, interventions, and outcomes;\n 4. Action plans:\n 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.\n 5. Medication Management;\n 6. Identify community/social services and family support;\n 7. Advanced directives",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Northern New England Practice Transformation Network in Collaboration with Mingle Analytics",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NNEPTN4",
    "title": "Transforming Clinical Practice Initiative Common Measure Name: TCPI 02: Referral of At-Risk Patients to Community Based Prevention and Support Resources",
    "description": "This is a measure to refer at risk patients of all ages to community resources to provide support and assist the patient with health promotion and prevention. The at-risk patient population for this measures includes:\n• BMI range >26;\n• Pre-diabetes;\n• Metabolic syndrome;\n• Behavioral/mental health ;\n• Substance use disorder.",
    "nationalQualityStrategyDomain": "Community/Population Health",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Northern New England Practice Transformation Network in Collaboration with Mingle Analytics",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "OEIS1",
    "title": "Optimal vascular care",
    "description": "This measure is a composite score of appropriate vascular care measures for treatment of PAD. This measure is a composite result of 1: Antiplatelet Therapy; 2: Preventive Care and Screening: Tobacco Use; and 3: Lipid-Lowering Medications (Statin) for Patients with PAD",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Outpatient Endovascular and Interventional Society- OEIS National Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": false,
    "isRiskAdjusted": false,
    "primarySteward": "Outpatient Endovascular and Interventional Society- OEIS National Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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- OEIS National Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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, Ezetemibe, Fibrates, PCSK9 Inhibitors.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Outpatient Endovascular and Interventional Society- OEIS National Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "OEIS5",
    "title": "Appropriate non-invasive arterial testing for patients with critical limb ischemia 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 critical limb ischemia.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "structure",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Outpatient Endovascular and Interventional Society- OEIS National Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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- OEIS National Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ONSQIR15",
    "title": "Assessment and Intervention for Psychosocial Distress in Adults Receiving Cancer Treatment",
    "description": "Percentage of patients aged 18 years 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 measurement period.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Oncology Nursing Society",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ONSQIR16",
    "title": "Recommendation for Exercise to Adult Cancer Survivors",
    "description": "Percentage of patients aged 18 years or older with a diagnosis of cancer who received a documented recommendation for 150 minutes of cardio, resistence and/or flexibility exercise at any visit during the measurement period.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Oncology Nursing Society",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ONSQIR17",
    "title": "Assessment and Intervention for Sleep-Wake Disturbance During Cancer Treatment",
    "description": "Percentage of chemotherapy cycles for patients aged 18 years and older with a diagnosis of cancer where a sleep-wake disturbance assessment is documented, and if moderate to severe disturbance is reported, an intervention for sleep-wake disturbance is documented.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Oncology Nursing Society",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ONSQIR6",
    "title": "Education on Neutropenia Precautions",
    "description": "Percentage of patients aged 18 years and older receiving intravenous chemotherapy who received education on neutropenia precautions prior to or at the time of the first chemotherapy administration. Instructions include hand washing and to contact health care provider of a fever of 101.0 or greater.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Oncology Nursing Society",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Oncology Nursing Society",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ONSQIR19",
    "title": "Post-Treatment Education",
    "description": "Percentage of patients aged 18 years and older for whom four critical areas of patient education regarding lifestyle, late effects and cancer recurrence have been provided or reinforcement of prior education has occurred.",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Oncology Nursing Society",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ONSQIR20",
    "title": "Fatigue Improvement",
    "description": "Percentage of patients aged 18 years and older who had moderate or greater fatigue at baseline (end of cancer treatment) and report improvement in fatigue from baseline to most recent visit in during the 12 month period after completing the final component of the treatment plan.",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Oncology Nursing Society",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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\n An eGFR (Estimated Glomerular Filtration Rate) test annually",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Physician Compass",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 <140/90, Tobacco Non-User, Statin Use, and Daily Aspirin or Other Antiplatelet for diabetes patients with IVD.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Physician Compass",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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:\nAll or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidney Function Monitoring Test and one eGFR Test",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Physician Compass",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "WCHQ13",
    "title": "Ischemic Vascular Disease Care Blood Pressure Control",
    "description": "The percentage of patients age 18 through 75 with one of the following conditions:\n 1) Two diagnoses related visits with Coronary Artery Disease (CAD) or a CAD risk-equivalent condition, or\n 2) Acute Coronary Event consisting of an acute myocardial infarction (AMI), coronary artery bypass graft (CABG), or percutaneous coronary intervention (PCI) from a hospital visit, who had each of the following during the one year measurement year:\n Most recent Blood pressure controlled to a level of less than 140/90 mm Hg",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Physician Compass",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACCPin1",
    "title": "Hypertension: Blood Pressure Control",
    "description": "Percentage of patients aged ≥18 years with a diagnosis of hypertension seen within a 12-month period who have a blood pressure <140/90 mm Hg, OR who have a blood pressure ≥140/90 mm Hg and were prescribed ≥2 antihypertensive medications during their most recent office visit",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ACCF-PINNACLE registry and Diabetes Collaborative Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACCPin2",
    "title": "CAD: Blood Pressure Control",
    "description": "Percentage of patients aged ≥18 years with a diagnosis of coronary artery disease seen within a 12-month period who have a blood pressure\n< 140/90 mm Hg, OR who have a blood pressure ≥140/90 mm Hg and were prescribed ≥2 antihypertensive medications during the most recent office visit",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ACCF-PINNACLE registry and Diabetes Collaborative Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACCPin3",
    "title": "HF: 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": "ACCF-PINNACLE registry and Diabetes Collaborative Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACCPin4",
    "title": "AFIB: CHA2DS2–VASc Score Risk Score Documented",
    "description": "Percent of patients, age 18 and older, with nonvalvular atrial fibrillation or atrial flutter for whom a CHA2DS2-VASc risk score is documented.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ACCF-PINNACLE registry and Diabetes Collaborative Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "PPRNET27",
    "title": "Use of Benzodiazepines in the Elderly",
    "description": "The percentage of patients 65 years and older who are prescribed a benzodiazepine and are on an appropriate dose",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "PPRNet",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "PPRNET28",
    "title": "NSAID or Cox 2 Inhibitor Use in Patients with Heart Failure (HF) 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. The CQM is aligned with a 2015 FDA Drug Safety Communication and corresponding NSAID label changes: “the risk of heart attack or stroke can occur as early as the first weeks.” Evidence from observational studies suggest that high risk patients (i.e. those eligible for the CQM) are at highest risk of harm in the first month of exposure.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "PPRNet",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "PPRNET30",
    "title": "Treatment of Hypokalemia",
    "description": "The percentage of adult patients prescribed a thiazide diuretic who have had a serum potassium measured in the past 12 months who have a serum potassium level ≥ 3.5 meq/L",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "PPRNet",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 Healthcare Solutions, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 Healthcare Solutions, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "Pinc3",
    "title": "Risk-adjusted 30 day Readmission for Pneumonia",
    "description": "Readmission 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 Healthcare Solutions, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "Pinc4",
    "title": "Risk-adjusted 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 Healthcare Solutions, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "Pinc5",
    "title": "Risk-adjusted Mortality for Heart Failure",
    "description": "Mortality during hospital admission for patients with a Principal Diagnosis of Heart Failure.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Premier Healthcare Solutions, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "Pinc6",
    "title": "Risk-adjusted Mortality for Pneumonia",
    "description": "Mortality during hospital admission for patients with a Principal Diagnosis of Pneumonia.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Premier Healthcare Solutions, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "Pinc33",
    "title": "Risk-Adjusted Average Length of Inpatient Hospital Stay for Acute Myocardial Infarction (AMI)",
    "description": "The average (geometric mean) hospital length of stay in days relative to the expected geometric mean length of stay of the AMI population of inpatients for the measurement year.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Premier Healthcare Solutions, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "Pinc34",
    "title": "Risk-Adjusted Average Length of Inpatient Hospital Stay for Heart Failure (HF)",
    "description": "The average (geometric mean) hospital length of stay in days relative to the expected geometric mean length of stay of the HF population of inpatients for the measurement year.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Premier Healthcare Solutions, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "Pinc35",
    "title": "Risk-Adjusted Average Length of Inpatient Hospital Stay for Pneumonia (PN)",
    "description": "The average (geometric mean) hospital length of stay in days relative to the expected geometric mean length of stay of the PN population of inpatients for the measurement year.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Premier Healthcare Solutions, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "Pinc53",
    "title": "Postoperative Sepsis Rate",
    "description": "Postoperative sepsis cases (secondary diagnosis) per 1,000 elective surgical discharges for patients ages 18 years and older. Excludes cases with a principal diagnosis of sepsis, cases with a secondary diagnosis of sepsis present on admission, cases with a principal diagnosis of infection, cases with a secondary diagnosis of infection present on admission (only if they also have a secondary diagnosis of sepsis), obstetric discharges, and cases with missing values as listed in denominator section.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Premier Healthcare Solutions, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "Pinc54",
    "title": "Iatrogenic Pneumothorax",
    "description": "Iatrogenic pneumothorax cases (secondary diagnosis) per 1,000 surgical and medical discharges for patients ages 18 years and older. Excludes cases with chest trauma, pleural effusion, thoracic surgery, lung or pleural biopsy, diaphragmatic repair, or cardiac procedures; cases with a principal diagnosis of iatrogenic pneumothorax; cases with a secondary diagnosis of iatrogenic pneumothorax present on admission; and obstetric cases",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Premier Healthcare Solutions, Inc.",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "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 at 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. The total rate includes the sum of persons with a therapeutic monitoring test at least once during the measurement year for angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB); serum potassium and a serum creatinine; digoxin and diuretics.\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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "sumNumerators",
    "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.\n•The percentage of individuals who received follow-up within 30 days of discharge\n•The percentage of individuals who received follow-up within 7 days of discharge",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "PsychPro",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "QOPI5",
    "title": "Chemotherapy administered to patients with metastatic solid tumors and performance status of 3,4, or undocumented (lower score-better)",
    "description": "Percentage of adult patients with metastatic solid tumors and performance status of 3, 4, or undocumented who receive chemotherapy (Lower score – better)",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "QOPI (ASCO)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "QOPI (ASCO)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 (ASCO)",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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. This is an Inverse Measure.",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Quantum Clinical Navigation System",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Quantum Clinical Navigation System",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "QUANTUM37",
    "title": "Gastric Aspiration",
    "description": "Any patient who aspirates gastric material into the lungs while sedated with general anesthesia or other sedative hypnotic agents administered by the anesthesia clinician, as determined by the anesthesia clinician and/or radiologic imaging up through anesthesia end time. Anesthesia End (Finish) Time is the time at which the anesthesiologist turns over care of the patient to a post anesthesia care team (either PACU or ICU). This time ends when the anesthesia team is no longer furnishing anesthesia services to the patient, that is when the patient may be placed safely under postoperative care and when the anesthesia team has completed transfer of patient care. This is an Inverse Measure.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Quantum Clinical Navigation System",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "QUANTUM42",
    "title": "Unplanned Hospital Admission After An Intended Outpatient Procedure",
    "description": "Patients who were scheduled for an outpatient surgical procedure who were subsequently admitted to an inpatient status related to the provision of anesthesia care.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Quantum Clinical Navigation System",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "QUANTUM51",
    "title": "Unplanned ICU Admission",
    "description": "Any patient who requires an unanticipated escalation in care necessitating a transfer to an ICU related to the provision of anesthesia care up through the time of PACU discharge. Reasons for admission may include a need for postoperative ventilation, ongoing vasopressor support, unanticipated unstable airway, unanticipated potential for apnea, unplanned prolonged anesthetic action or neuromuscular blockade. This is an Inverse Measure.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Quantum Clinical Navigation System",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAO8",
    "title": "Otitis Media with Effusion: Antihistamines or Decongestants – Avoidance of Inappropriate Use",
    "description": "\"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\n Rationale: OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. No data exists to support antihistamines and decongestants in treating OME. As a result, physicians should not prescribe or recommend the over-the-counter use of these medications.\n The purpose of the corresponding guideline statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the vast majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME.\n\n Evidence: STATEMENT 8c. ANTIHISTAMINES OR DECONGESTANTS: Clinicians should recommend against using antihistamines, decongestants, or both for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit.\n\n Clinical Practice Guideline: Otitis Media with Effusion (Update). Rosenfeld RM et al. Otolaryngol Head Neck Surg. (2016)\"",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "REG-ENT The American Academy of Otolaryngology - Head and Neck Surgery Foundation Clinical Data Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAO9",
    "title": "Otitis Media with Effusion: Systemic Corticosteroids – Avoidance of Inappropriate Use",
    "description": "\"Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic corticosteroids\n\n Rationale: OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. Systemic steroids have no proven long-term effectiveness and have potential adverse effects.\n\n The purpose of the corresponding guideline statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the vast majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME.\n\n Evidence: STATEMENT 8a. STEROIDS: Clinicians should recommend against using intranasal steroids or systemic steroids for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit.\n\n Clinical Practice Guideline: Otitis Media with Effusion (Update). Rosenfeld RM et al. Otolaryngoly Head Neck Surg. (2016)\"",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "REG-ENT The American Academy of Otolaryngology - Head and Neck Surgery Foundation Clinical Data Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAO10",
    "title": "Otitis Media with Effusion: Systemic Antimicrobials – Avoidance of Inappropriate Use",
    "description": "\"Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials\n\n Rationale: OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. Systemic antimicrobials have no proven long-term effectiveness and have potential adverse effects.\n\n The purpose of the corresponding guideline statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the vast majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME.\n\n Evidence: STATEMENT 8b. ANTIBIOTICS: Clinicians should recommend against using systemic antibiotics for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit.\n\n Clinical Practice Guideline: Otitis Media with Effusion (Update). Rosenfeld RM et al. Otolaryngoly Head Neck Surg. (2016)\"",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "REG-ENT The American Academy of Otolaryngology - Head and Neck Surgery Foundation Clinical Data Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAO11",
    "title": "Otitis Media with Effusion: Avoidance of Topical Intranasal Corticosteroids",
    "description": "\"Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed topical intranasal corticosteroids\n\n Rationale: OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. In children aged 4 to 11 years, there was no difference in the resolution of effusion or hearing loss over 3 months between children treated with nasal mometasone or placebo; in fact, there was an economic disadvantage in the group treated with mometasone, considering the high rate of spontaneous resolution in the placebo group. Furthermore, 7% to 22% of study group patients experienced minor adverse effects.\n\n The purpose of the corresponding guideline action statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME.\n\n Evidence: STATEMENT 8a. STEROIDS: Clinicians should recommend against using intranasal steroids or systemic steroids for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit.\n\n Clinical Practice Guideline: Otitis Media with Effusion (Update). Rosenfeld RM et al. Otolaryngoly Head Neck Surg. (2016)\"",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "REG-ENT The American Academy of Otolaryngology - Head and Neck Surgery Foundation Clinical Data Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 under procedure sedation analgesia.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Renal Physicians Association",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RPAQIR12",
    "title": "Arterial Complication Rate Following Arteriovenous Access Intervention",
    "description": "Percentage of arterial complications following angiography, angioplasty or thrombectomy procedures.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Renal Physicians Association",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RPAQIR14",
    "title": "Arteriovenious Graft Thrombectomy Success Rate",
    "description": "Percentage of clinically successful arteriovenous graft (AVG) thrombectomies.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal Physicians Association",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RPAQIR15",
    "title": "Arteriovenous Fistulae Thrombectomy Success Rate",
    "description": "Percentage of clinically successful arteriovenous fistulae (AVF) thrombectomies.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal Physicians Association",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 years and older with a diagnosis for CKD 3-5 that have been seen by the nephrologist or nephrologist’s team member in the office setting within the lowest value of the suggested frequency range per the Kidney Disease: Improving Global Outcomes (KDIGO).\n\nWe will report a simple cumulative score of the sum of the numerators / sum of the denominators\n\nMeasure Rates to be Reported:\n\nRate 1: CKD 3 Patients with 2 or more visits/yr.\nRate 2: CKD 4 Patients with 3 or more visits/yr.\nRate 3: CKD 5 Patients with 8 or more visits/yr.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal and Cardiovascular Outcome Improvement Program, powered by Forward Health Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "weightedAverage",
    "strata": [
      {
        "name": "CKD3",
        "description": "CKD 3 Patients with 2 or more visits/yr."
      },
      {
        "name": "CKD4",
        "description": "CKD 4 Patients with 3 or more visits/yr."
      },
      {
        "name": "CKD5",
        "description": "CKD 5 Patients with 8 or more visits/yr."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RCOIR2",
    "title": "Patients with a Visit to a Nephrologists Prior to 6 Months of Dialysis Onset",
    "description": "Patients with a Visit to a Nephrologists Prior to 6 Months of Dialysis Onset is the percent of patients aged 18 years and older that had an office visit with a nephrologist 6 months prior to the onset of dialysis.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal and Cardiovascular Outcome Improvement Program, powered by Forward Health Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 years and older with a diagnosis for CKD 3-5 and not receiving Renal Replacement Treatment that have had a urine albumin to creatinine ratio lab test (ACR) or urine protein to creatinine ratio lab test (PCR) performed within the measurement period.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal and Cardiovascular Outcome Improvement Program, powered by Forward Health Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 a diagnosis for CKD 4-5 who are referred to a transplant center for kidney transplant evaluation within a 24 month period.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal and Cardiovascular Outcome Improvement Program, powered by Forward Health Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RCOIR5",
    "title": "End Stage Renal Disease (ESRD) Initiation of Home Dialysis or Self-Care",
    "description": "End Stage Renal Disease (ESRD) Initiation of Home Dialysis or Self-Care is the percentage of all adult ESRD patients on peritoneal dialysis (PD) or home hemodialysis.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal and Cardiovascular Outcome Improvement Program, powered by Forward Health Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RCOIR6",
    "title": "End Stage Renal Disease (ESRD) Missed Dialysis Treatments",
    "description": "End Stage Renal Disease (ESRD) Missed Dialysis Treatments is the percentage of adult ESRD patients that completed all scheduled dialysis treatments during the most recent calendar month.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal and Cardiovascular Outcome Improvement Program, powered by Forward Health Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 that presented for prolonged bleeding, received an intervention, and subsequently reported a reduction in post-dialysis bleeding.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal and Cardiovascular Outcome Improvement Program, powered by Forward Health Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 intervention performed and reported no post procedural bleeding complications.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal and Cardiovascular Outcome Improvement Program, powered by Forward Health Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RCOIR9",
    "title": "Post Procedure Infection",
    "description": "Post Procedure Infection is the percentage of patients with ESRD that had any peripheral vascular intervention performed and reported no post procedural signs or symptoms of infection as defined as fever, chills, localized erythema or active draining of pus or new abscess formation.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal and Cardiovascular Outcome Improvement Program, powered by Forward Health Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 extremity 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 Cardiovascular Outcome Improvement Program, powered by Forward Health Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RPAQIR1",
    "title": "Angiotensin Converting Enzyme (ACE) Inhibitor or AngiotensinReceptor 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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 ESRD and receiving maintenance hemodialysis are using an autogenous arteriovenous (AV) fistula with two needles.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal Physicians Association",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RPAQIR5",
    "title": "Transplant Referral",
    "description": "Percentage of patients aged 18 years and older with a diagnosis of 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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal Physicians Association",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RPAQIR16",
    "title": "Peritoneal Dialysis Catheter Success Rate",
    "description": "Percentage of clinically successful peritoneal dialysis (PD) catheter placements.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal Physicians Association",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Renal Physicians Association",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal Physicians Association",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ICLOPS15",
    "title": "Excess Days Rate and Degree of Excess (Including Physician Response)",
    "description": "This is a two-part measure, measuring rate of discharges with no excess days and, where excess days occur, the rate of overly excess days. Physician feedback is required to satisfy requirements. Patients will be assigned to a physician’s Registry based on identification within the Hospital Quality dataset. The patient will be matched to existing patient data within this physician’s source system using the standard Roji Health Intelligence patient-matching algorithm (utilizing the data elements listed previously). Patients within the data who cannot be matched to patients within the physician source system data will be displayed, but flagged for review and validation.\nRate 1: the percentage of discharges without excess days out of the total of all-cause discharges for patients aged 18 years and older.\nRate 2: the percentage of discharges with excess days where clinician provided the required feedback AND where excess days numbered less than 3, out of the total number of discharges with excess days.",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Roji Health Intelligence LLC",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "weightedAverage",
    "strata": [
      {
        "name": "withoutexcess",
        "description": "the percentage of discharges without excess days out of the total of all-cause discharges for patients aged 18 years and older."
      },
      {
        "name": "withexcess",
        "description": "the percentage of discharges with excess days where clinician provided the required feedback AND where excess days numbered less than 3, out of the total number of discharges with excess days."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ICLOPS17",
    "title": "Rate of Follow Up Visits Within 7 Days of Discharge (Including Physician Response)",
    "description": "This is a two-part measure, measuring whether patients were seen in a timely fashion in the ambulatory setting after discharge.  Physician feedback is required to satisfy requirements. Patients will be assigned to a physician’s Registry based on identification within the Hospital Quality dataset. The patient will be matched to existing patient data within this physician’s source system using the standard Roji Health Intelligence patient-matching algorithm (utilizing the data elements listed previously). Patients within the data who cannot be matched to patients within the physician source system data will be displayed, but flagged for review and validation.\nRate 1: the percentage of discharges where there is a subsequent office visit within seven days out of the total number of of all-cause discharges for patients aged 18 years and older.\nRate 2: the percentage of discharges without subsequent office visits within 7 days where clinician provided required feedback AND where re-admission within 30 days did not occur, out of the total number of all-cause discharges for patients aged 18 years and older.",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Roji Health Intelligence LLC",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "weightedAverage",
    "strata": [
      {
        "name": "withfollowup",
        "description": "the percentage of discharges where there is a subsequent office visit within seven days out of the total number of of all-cause discharges for patients aged 18 years and older."
      },
      {
        "name": "withoutfollowup",
        "description": "the percentage of discharges without subsequent office visits within 7 days where clinician provided required feedback AND where re-admission within 30 days did not occur, out of the total number of all-cause discharges for patients aged 18 years and older."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RHI1",
    "title": "Diabetic patients with significant change in HgbA1C level or overall change in HgbA1C",
    "description": "This measure examines changes in Hemoglobin A1c using 3 Performance Rates:\nPerformance Rate 1: The percentage of patients aged 18-75 years whose most recent Hemoglobin A1c has decreased by at least 1% from the highest level to the most recent level out of all patients with at  least 2 Hemoglobin A1c levels in the measurement year or year prior to the measurement year with at least one Hemgolobin A1c greater than or equal to 9%.\nPerformance rate 2: The percentage of patients aged 18-75 years whose most recent Hemoglobin A1c has increased by at least 1% from the lowest level to the most Hemoglobin A1c, out of all patients with at least 2 Hemoglobin A1c levels in the measurement year or year prior to the measurement year with at least one Hemoglobin A1c less than 9%.\nPerformance Rate 3: The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator.  Performance Rate 3 is the final performance rate for this measure.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Roji Health Intelligence LLC",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "<9",
        "description": "The percentage of patients aged 18-75 years whose most recent Hemoglobin A1c has decreased by at least 1% from the highest level to the most recent level out of all patients with at  least 2 Hemoglobin A1c levels in the measurement year or year prior to the measurement year with at least one Hemgolobin A1c greater than or equal to 9%.\nPerformance"
      },
      {
        "name": ">=9",
        "description": "The percentage of patients aged 18-75 years whose most recent Hemoglobin A1c has increased by at least 1% from the lowest level to the most Hemoglobin A1c, out of all patients with at least 2 Hemoglobin A1c levels in the measurement year or year prior to the measurement year with at least one Hemoglobin A1c less than 9%.\nPerformance"
      },
      {
        "name": "overall",
        "description": "The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator.  Performance Rate 3 is the final performance rate for this measure."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RHI2",
    "title": "Hypertensive patients with significant change in systolic blood pressure or overall change in systolic pressure",
    "description": "This measure examines changes in systlic blood pressure using 3 Performance Rates:\nPerformance Rate 1: The percentage of patients aged 50-75 years whose most recent systolic blood pressure has decreased by at least 20 mmHg from the highest level to the most recent level out of all patients with at least 2 systolic blood pressure readings in the measurement year or year prior to the measurement year with at least one systolic blood pressure greater than or equal to 160 mmHg.\nPerformance rate 2: The percentage of patients aged 50-75 years whose most recent systolic blood pressure has increased by at least 20 mmHg from the lowest level to the most systolic blood pressure, out of all patients with at least 2 systolic blood pressure readings in the measurement year or year prior to the measurement year with at least one systolic blood pressure less than 160 mmHg.\nPerformance Rate 3: The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator.  Performance Rate 3 is the final performance rate for this measure.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Roji Health Intelligence LLC",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": ">=160",
        "description": "The percentage of patients aged 50-75 years whose most recent systolic blood pressure has decreased by at least 20 mmHg from the highest level to the most recent level out of all patients with at least 2 systolic blood pressure readings in the measurement year or year prior to the measurement year with at least one systolic blood pressure greater than or equal to 160 mmHg.\nPerformance"
      },
      {
        "name": "<160",
        "description": "The percentage of patients aged 50-75 years whose most recent systolic blood pressure has increased by at least 20 mmHg from the lowest level to the most systolic blood pressure, out of all patients with at least 2 systolic blood pressure readings in the measurement year or year prior to the measurement year with at least one systolic blood pressure less than 160 mmHg.\nPerformance"
      },
      {
        "name": "overall",
        "description": "The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator.  Performance Rate 3 is the final performance rate for this measure."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RHI3",
    "title": "Patients who have a change in tobacco use status (Improvement)",
    "description": "The percent of patients whose most  recent tobacco use status is not smoking and at least one of the prior responses is currently smoking   over the number of patients with no change in smoking status  or smoking status changed from not a current smoker to smoker.  This measure is for patient >2 office visits in the measurement year and the prior year (at least 1 must be in the measurement year) AND have an assessment of smoking status at least twice.",
    "nationalQualityStrategyDomain": "Community/Population Health",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Roji Health Intelligence LLC",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RHI4",
    "title": "Patients with Change in BMI",
    "description": "This measure examines BMI changes using  3 Performance Rates:\nPerformance Rate 1: The percentage of patients 18 years and older whose most recent BMI has decreased by at least 5 from the highest level to the most recent BMI out of all patients with at  least 2 BMI levels in the measurement year or year prior to the measurement year with at least one BMI greater than or equal to 35.\nPerformance rate 2: The percentage of patients 18 years and older whose most recent BMI has increased by at least 5 from the lowest level to the most recent BMI, out of all patients with at least 2 BMI levels in the measurement year or year prior to the measurement year with at least one BMI less than 35.\nPerformance Rate 3: The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator.  Performance Rate 3 is the final performance rate for this measure.",
    "nationalQualityStrategyDomain": "Community/Population Health",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Roji Health Intelligence LLC",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "decreased",
        "description": "The percentage of patients 18 years and older whose most recent BMI has decreased by at least 5 from the highest level to the most recent BMI out of all patients with at  least 2 BMI levels in the measurement year or year prior to the measurement year with at least one BMI greater than or equal to 35.\nPerformance"
      },
      {
        "name": "increased",
        "description": "The percentage of patients 18 years and older whose most recent BMI has increased by at least 5 from the lowest level to the most recent BMI, out of all patients with at least 2 BMI levels in the measurement year or year prior to the measurement year with at least one BMI less than 35.\nPerformance"
      },
      {
        "name": "overall",
        "description": "The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator.  Performance Rate 3 is the final performance rate for this measure."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RHI5",
    "title": "Low back pain patients who undergo an operative procedure on the spine within 12 weeks after a referral from a primary care physician",
    "description": "Percent of patients with a diagnosis of low back pain who undergo an  operative  procedure on the spine within 12 weeks  of an initial consultation",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Roji Health Intelligence LLC",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RHI6",
    "title": "Breast Mass Follow Up: Percent of patients with a breast mass who do not have follow-up physician contact",
    "description": "The percentage of patients with a breast mass who are lost to follow-up",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Roji Health Intelligence LLC",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RHI7",
    "title": "Uncontrolled chronic disease patients without a follow-up office visit",
    "description": "Patients with hypertension OR diabetes mellitus OR CHF OR Asthma OR COPD who have not been seen in the office within six months of an encounter where there was evidence that the condition was uncontrolled",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Roji Health Intelligence LLC",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "SCG1",
    "title": "Evaluation of High Risk Pain Medications for Morphine Milligram Equivalents (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": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "Searfoss Consulting Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "SCG2",
    "title": "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "Searfoss Consulting Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "Searfoss Consulting Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "SCG4",
    "title": "Prevention of Antibiotic or Natural Herbal Supplement Impairment of Anesthesia",
    "description": "Percentage of patients, regardless of age, who are were prescribed antibiotics or taking natural herbal supplements and undergoing a surgical, therapeutic or diagnostic procedures\nunder anesthesia during the performance period and who have a documented use of a preoperative\nassessment for anesthesia impairment, documented cross activity and/or\ncontraindication where appropriate AND there was no impairment of the effectiveness of\nanesthesia\nThree rates are reported.\n1) Percentage of patients who were screened using a pre-operative assessment of antibiotic\ndrug combination or natural/herbal supplement usage\n2) Percentage of patients identified with a cross activity or contraindication in the\nassessment\n3) Percentage of patients experiencing no impairment of the effectiveness of anesthesia",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "Searfoss Consulting Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "SCG05",
    "title": "Improvement in Quality of Life from Partial Foot, Prosthetics",
    "description": "Percentage of patients 18 years and older with a prescription for a partial foot, prosthetic to assist with ambulation whose health related quality of life (HRQoL) was assessed during at least two visits during the performance period AND whose health related quality of life score stayed the same or improved",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "Searfoss Consulting Group",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 their PCP for that screening",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Society of Dermatology Physician Assistants Dermatology PA QCDR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Society of Dermatology Physician Assistants Dermatology PA QCDR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "SDPAD3",
    "title": "Avoiding antibiotic use in ruptured 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": "Effective Clinical Care",
    "measureType": "efficiency",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Society of Dermatology Physician Assistants Dermatology PA QCDR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 or Patient safety",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Society of Dermatology Physician Assistants Dermatology PA QCDR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Society of Thoracic Surgeons",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Society of Thoracic Surgeons",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Society of Thoracic Surgeons",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "patientEngagementExperience",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Society of Thoracic Surgeons",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "SMX1",
    "title": "Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia",
    "description": "The percentage of patients 25 – 75 years of age with schizophrenia and cardiovascular disease, who had an LDL-C test during the program year",
    "nationalQualityStrategyDomain": "Community/Population Health",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "SpectraMedix eMeasures360 QCDR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "SMX2",
    "title": "Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications",
    "description": "The 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 program year.",
    "nationalQualityStrategyDomain": "Community/Population Health",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "SpectraMedix eMeasures360 QCDR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "SMX3",
    "title": "Use of Multiple Concurrent Antipsychotics in Children and Adolescents",
    "description": "The percentage of children and adolescents 1–17 years of age who were on two or more concurrent antipsychotic medications.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "SpectraMedix eMeasures360 QCDR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "SMX4",
    "title": "Metabolic Monitoring for Children and Adolescents on Antipsychotics",
    "description": "The percentage of children and adolescents 1–17 years of age who had two or more antipsychotic prescriptions and had metabolic testing.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "SpectraMedix eMeasures360 QCDR",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "The American Joint Replacement Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AJRR2",
    "title": "Hip Arthroplasty: Health and Functional Improvement",
    "description": "Percentage of patients undergoing a hip arthroplasty who reported functional status based on the Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR,) AND either the NIH PROMIS-10 Global instrument OR the VR-12 during the preoperative visit within 3 months prior to the procedure and at the postoperative visit between 180 and 365 days following the procedure.",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "The American Joint Replacement Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "The American Joint Replacement Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "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": "The American Joint Replacement Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "ASBS10: Percent of Z0011 eligible breast cancer patients who do not undergo completion axillary dissection",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "The American Society of Breast Surgeons",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 secondary 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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "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": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NIPM5",
    "title": "APPROPRIATE PATIENT SELECTION FOR TRIAL SPINAL CORD STIMULATION",
    "description": "Measurement of proportion of patients aged 18 years or older meeting appropriate patient selection criteria for trial spinal cord stimulation.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NIPM6",
    "title": "APPROPRIATE PATIENT SELECTION FOR USE OF EPIDURAL INJECTIONS IN MANAGING PAIN ORIGINATING IN THE SACRAL, LUMBAR, THORACIC OR CERVICAL SPINE",
    "description": "Measurement of proportion of patients aged 18 years and older meeting appropriate patient selection criteria for therapeutic epidural injections.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NIPM8",
    "title": "AVOIDING EXCESSIVE USE OF EPIDURAL INJECTIONS IN MANAGING CHRONIC PAIN ORIGINATING IN THE CERVICAL AND THORACIC SPINE\n\n(Measure 18)",
    "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": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NIPM1",
    "title": "AVOIDING EXCESSIVE USE OF EPIDURAL INJECTIONS IN MANAGING CHRONIC PAIN ORIGINATING IN THE LUMBOSACRAL SPINE",
    "description": "Measurement of percentage of patients aged 18 years and older receiving therapeutic lumbosacral epidural injections that do not receive an excessive number of injections during the measurement period.",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NIPM9",
    "title": "AVOIDING EXCESSIVE USE OF THERAPEUTIC FACET JOINT INTERVENTIONS IN MANAGING CHRONIC CERVICAL AND THORACIC SPINAL PAIN\n\n(Measure 19)",
    "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": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NIPM3",
    "title": "AVOIDING EXCESSIVE USE OF THERAPEUTIC FACET JOINT INTERVENTIONS IN MANAGING CHRONIC LUMBAR SPINAL PAIN",
    "description": "Measurement of percentage of patients aged 18 years and older receiving lumbar 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": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NIPM2",
    "title": "RATE OF CAUDAL AND INTERLAMINAR EPIDURAL INJECTIONS WITHOUT DURAL PUNCTURE",
    "description": "Measurement of percentage of patients aged 18 years and older undergoing epidural injections with a caudal approach or lumbar, thoracic or cervical interlaminar approach during the reporting period who have not experienced dural puncture during the procedure.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NIPM7",
    "title": "SHARED DECISION MAKING REGARDING ANTICOAGULANT AND ANTITHROMBOTIC USE IN THE SETTING OF CAUDAL OR INTERLAMINAR EPIDURAL INJECTIONS",
    "description": "Measurement of percentage of patients aged 18 years and older undergoing caudal or interlaminar epidural injections with documentation of appropriate discussion, risk/benefit analysis, and shared decision making regarding continuation or discontinuation of their anticoagulation or antithrombotic regimen.",
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CAP1",
    "title": "Topic: Turnaround time (TAT) for 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": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "The College of American Pathologists",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CAP2",
    "title": "Cancer Protocol Elements for Carcinoma of the Endometrium Completed",
    "description": "Cancer checklist used for all eligible Carcinoma of the Endometrium specimens and all required data elements are included.  The checklist covers the following procedure –                                             Hysterectomy with/without salpingoophorectomy",
    "nationalQualityStrategyDomain": "Clinical Process/Effectiveness",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "The College of American Pathologists",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CAP3",
    "title": "Cancer Protocol Elements for Invasive Carcinoma of Renal Tubular Origin Completed",
    "description": "Cancer checklist used for all eligible kidney resections and all required data elements are included.  The checklist covers the following procedures –\n\n• Partial Nephrectomy\n• Radical Nephrectomy",
    "nationalQualityStrategyDomain": "Clinical Process/Effectiveness",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "The College of American Pathologists",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CAP4",
    "title": "Cancer Protocol Elements for Carcinoma of the Intrahepatic Bile Ducts Completed",
    "description": "• Cancer checklist 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": "Clinical Process/Effectiveness",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "The College of American Pathologists",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "Clinical Process/Effectiveness",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "The College of American Pathologists",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CAP6",
    "title": "Cancer Protocol Elements for Carcinoma of the Pancreas Completed",
    "description": "Cancer checklist used for all eligible all epithelial tumors of the pancreas, including high-grade neuroendocrine carcinomas.  The checklist covers the following procedures –\n• Partial Pancreatectomy\n• Pancreaticoduodenectomy (Whipple Resection)\n• Total Pancreatectomy",
    "nationalQualityStrategyDomain": "Clinical Process/Effectiveness",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "The College of American Pathologists",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "SPINEIQ1",
    "title": "Change in Functional Outcomes",
    "description": "Average percentage decrease in PROMIS Pain Interference Score for all episodes of care for back or neck pain.\n\nNOTE: Negative decreases (or increases in pain inference) for a provider's overall score are reported as a 0% reduction.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "The Spine Institute for Quality",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "SPINEIQ2",
    "title": "Change in Pain Intensity",
    "description": "Average percentage decrease in PROMIS Pain Intensity Score for all episodes of care for back or neck pain.\n\nNOTE: Negative decreases (or increases in pain inference) for a provider's overall score are reported as a 0% reduction.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "The Spine Institute for Quality",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "SPINEIQ3",
    "title": "Repeated X-ray Imaging",
    "description": "Percent of patients with back or neck pain who receive two or more of the same x-ray imaging studies within the measurement period. (inverse Measurement)",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "The Spine Institute for Quality",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "outcome",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Universal Research Solutions - OBERD",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Universal Research Solutions - OBERD",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "OBERD24",
    "title": "Inflamatory Bowel Disease: Follow-up and Outcomes",
    "description": "This measure is a translation of the recommendations of ICHOM for optimum IBD patient follow-up using an appropriate patient reported outcome (PRO) instrument to to measure symptoms and activities of daily living. IBD-Control is such an instrument, available without license or fees provided the original paper is cited in any publication (see Bodger, et al, Gut 2014;63(7):1092-102). This measure requires that adequate disease control is demonstrated.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Universal Research Solutions - OBERD",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "OBERD12",
    "title": "Patient Satisfaction: CG-CAHPS Composite Tracking v",
    "description": "Patient Satisfaction has become a recognized responsibility of the healthcare community that ultimately resides with the EC. This measure is intended to encourage the administration of CG-CAHPS to all patients at each visit and to ensure that attention is focused on the actionable items in the instrument, as summarized in four of the composites: Getting Timely Appointments, Care, and Information;How Well Providers Communicate With Patients; Helpful, Courteous, and Respectful Office Staff; and Follow-up on Test Results. This questionnaire is collected like any other patient reported outcome by the QCDR; it differs from the \"CAHPS for MIPS\" in that it is much shorter and does not require a special vendor.",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Universal Research Solutions - OBERD",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "OBERD25",
    "title": "Patient Satisfaction: 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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Universal Research Solutions - OBERD",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CDR5",
    "title": "Adequate Compression of Venous Leg Ulcers at each treatment visit",
    "description": "Percentage of venous leg ulcer visits among patients aged 18 years and older received adequate compression within the 12-month reporting period.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "U.S. Wound Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 ulcers (VLUs)",
    "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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "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": "efficiency",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "U.S. Wound Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "USWR15",
    "title": "Healing or Closure of Wagner Grade 3, 4 or 5 Diabetic Foot Ulcers (DFUs) Treated with HBOT",
    "description": "Percentage diabetic foot 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 achieved healing or closure 6 months after completion of a course of HBOT, stratified by the Wound Healing Index. Healing or closure is defined as an ulcer with epithelial coverage and no continued drainage requiring a dressing.\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": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "U.S. Wound Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "USWR16",
    "title": "Major Amputation in Wagner Grade 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",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "U.S. Wound Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "U.S. Wound Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "USWR13",
    "title": "Patient Vital Sign Assessment and Blood Glucose Check Prior to Hyperbaric Oxygen\nTherapy (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\n(HBOT).  Three rates are reported for this measure.\n\nRate 1: Percentage 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": false,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "U.S. Wound Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "CDR3",
    "title": "Plan of Care Creation for Diabetic Foot Ulcers (DFU) not Achieving 30% Closure at 4 Weeks",
    "description": "Percentage of diabetic foot 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.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "U.S. Wound Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CDR7",
    "title": "Plan of Care for Venous Leg Ulcers not Achieving 30% Closure at 4 Weeks",
    "description": "Percentage of patients aged 18 years or older with a diagnosis of venous leg ulcer for 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.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "U.S. Wound Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CDR10",
    "title": "Vascular Assessment of patients with chronic leg ulcers",
    "description": "Percentage of patients aged 18 years or older with a non healing lower extremity Diabetic Foot Ulcer (DFU), Venous Leg UIcer (VLU), or pressure ulcer of the lower extremity that underwent a non-invasive baseline vascular assessment once in a 12 month period",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "U.S. Wound Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CDR6",
    "title": "Venous Leg Ulcer 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.\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: 0.00-73.24\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 Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "U.S. Wound Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "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": "USWR21",
    "title": "Wound Outcome",
    "description": "Completion of Wound Outcome Questionnaire by eligible patients once during the 12-month reporting period by patients 18 years of age or older who are discharged or transferred to another site of care.",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "U.S. Wound Registry",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "WCQIC16",
    "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. Using 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": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Wound Care Collaborative",
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  }
]