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"E13.29", "E13.311", "E13.319", "E13.3211", "E13.3212", "E13.3213", "E13.3219", "E13.3291", "E13.3292", "E13.3293", "E13.3299", "E13.3311", "E13.3312", "E13.3313", "E13.3319", "E13.3391", "E13.3392", "E13.3393", "E13.3399", "E13.3411", "E13.3412", "E13.3413", "E13.3419", "E13.3491", "E13.3492", "E13.3493", "E13.3499", "E13.3511", "E13.3512", "E13.3513", "E13.3519", "E13.3521", "E13.3522", "E13.3523", "E13.3529", "E13.3531", "E13.3532", "E13.3533", "E13.3539", "E13.3541", "E13.3542", "E13.3543", "E13.3549", "E13.3551", "E13.3552", "E13.3553", "E13.3559", "E13.3591", "E13.3592", "E13.3593", "E13.3599", "E13.36", "E13.37X1", "E13.37X2", "E13.37X3", "E13.37X9", "E13.39", "E13.40", "E13.41", "E13.42", "E13.43", "E13.44", "E13.49", "E13.51", "E13.52", "E13.59", "E13.610", "E13.618", "E13.620", "E13.621", "E13.622", "E13.628", "E13.630", "E13.638", "E13.641", "E13.649", "E13.65", "E13.69", "E13.8", "E13.9", "O24.011", "O24.012", "O24.013", "O24.019", "O24.02", "O24.03", "O24.111", "O24.112", "O24.113", "O24.119", "O24.12", "O24.13", "O24.311", "O24.312", "O24.313", "O24.319", "O24.32", "O24.33", "O24.811", "O24.812", "O24.813", "O24.819", "O24.82", "O24.83" ], "maxAge": 75, "minAge": 18, "procedureCodes": [ { "code": "97802" }, { "code": "97803" }, { "code": "97804" }, { "code": "99201" }, { "code": "99202" }, { "code": "99203" }, { "code": "99204" }, { "code": "99205" }, { "code": "99211" }, { "code": "99212" }, { "code": "99213" }, { "code": "99214" }, { "code": "99215" }, { "code": "99217" }, { "code": "99218" }, { "code": "99219" }, { "code": "99220" }, { "code": "99221" }, { "code": "99222" }, { "code": "99223" }, { "code": "99231" }, { "code": "99232" }, { "code": "99233" }, { "code": "99238" }, { "code": "99239" }, { "code": "99281" }, { "code": "99282" }, { "code": "99283" }, { "code": "99284" }, { "code": "99285" }, { "code": "99291" }, { "code": "99304" }, { "code": "99305" }, { "code": "99306" }, { "code": "99307" }, { "code": "99308" }, { "code": "99309" }, { "code": "99310" }, { "code": "99315" }, { "code": "99316" }, { "code": "99318" }, { "code": "99324" }, { "code": "99325" }, { "code": "99326" }, { "code": "99327" }, { "code": "99328" }, { "code": "99334" }, { "code": "99335" }, { "code": "99336" }, { "code": "99337" }, { "code": "99341" }, { "code": "99342" }, { "code": "99343" }, { "code": "99344" }, { "code": "99345" }, { "code": "99347" }, { "code": "99348" }, { "code": "99349" }, { "code": "99350" }, { "code": "G0270" }, { "code": "G0271" }, { "code": "G0402" }, { "code": "G0438" }, { "code": "G0439" } ] } ], "performanceOptions": [ { "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9687" } ] }, { "optionType": "performanceNotMet", "qualityCodes": [ { "code": "3044F", "modifierExclusions": [ "1P", "2P", "3P", "8P" ] } ] }, { "optionType": "performanceNotMet", "qualityCodes": [ { "code": "3045F", "modifierExclusions": [ "1P", "2P", "3P", "8P" ] } ] }, { "optionType": "performanceMet", "qualityCodes": [ { "code": "3046F", "modifierExclusions": [ "1P", "2P", "3P" ], "modifiers": [ "8P" ] } ] }, { "optionType": "performanceMet", "qualityCodes": [ { "code": "3046F", "modifierExclusions": [ "1P", "2P", "3P", "8P" ] } ] } ] }, { "title": "Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)", "eMeasureId": "CMS135v7", "nqfEMeasureId": "0081e", "nqfId": "0081", "measureId": "005", "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": "Effective Clinical Care", "measureType": "process", "primarySteward": "Physician Consortium for Performance Improvement", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "hospitalists" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_005_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2019/cms135v7" }, "eMeasureUuid": "40280382-6240-b6b9-0162-5462542a0b59", "strata": [ { "name": "Within12Months", "description": "Patients who were prescribed ACE inhibitor or ARB therapy within a 12-month period", "eMeasureUuids": { "initialPopulationUuid": "24092CC9-3820-4099-9F70-D0BFAC65AE89", "denominatorUuid": "D18CEF8F-9533-4B09-8A69-003F327CE469", "numeratorUuid": "41EF9FF5-7260-41D8-88E6-760F876C66FB", "denominatorExceptionUuid": "635D1D87-8196-453D-9A80-332E6FBD4F7F" } }, { "name": "HospitalDischarge", "description": "Patients who were prescribed ACE inhibitor or ARB therapy at each hospital discharge", "eMeasureUuids": { "initialPopulationUuid": "B859035C-8ECD-4F04-86D9-546BBF293396", "denominatorUuid": "89C9D1EC-FDAD-4982-9CE4-F144E8A85A53", "numeratorUuid": "88762E67-6197-4F77-9800-46707A34C062", "denominatorExceptionUuid": "1504BDD4-8AAD-4B91-87C3-5F0B12B6E97D" } } ] }, { "title": "Coronary Artery Disease (CAD): Antiplatelet Therapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0067", "measureId": "006", "description": "Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12 month period who were prescribed aspirin or clopidogrel", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Heart Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "skilledNursingFacility" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_006_MIPSCQM.pdf" } }, { "title": "Coronary Artery Disease (CAD): Beta-Blocker Therapy - Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)", "eMeasureId": "CMS145v7", "nqfEMeasureId": null, "nqfId": "0070", "measureId": "007", "description": "Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period who also have a prior MI or a current or prior LVEF < 40% who were prescribed beta-blocker therapy", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "Physician Consortium for Performance Improvement", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "overallAlgorithm": "weightedAverage", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "skilledNursingFacility" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_007_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2019/cms145v7" }, "strata": [ { "name": "LVSD", "description": "Percentage of patients with a diagnosis of CAD or history of cardiac surgery who have a current or prior LVEF < 40% who were prescribed beta-blocker therapy", "eMeasureUuids": { "initialPopulationUuid": "D37F8791-745C-422B-AC54-AFE90EF73403", "denominatorUuid": "FA3204A5-C7E7-4DCF-883C-E30E1EAF6B15", "numeratorUuid": "B0B86C82-753C-41B6-ABC0-C40605738B19", "denominatorExceptionUuid": "5C10D849-3AAF-4AB8-AC42-C41593EA4B41" } }, { "name": "priorMI", "description": "Percentage of patients with a diagnosis of CAD or history of cardiac surgery who have a prior (within the past 3 years) myocardial infarction who were prescribed beta-blocker therapy", "eMeasureUuids": { "initialPopulationUuid": "FF8E828F-3079-422E-8A60-DC7E07DC04EB", "denominatorUuid": "87EBA461-3E66-45D9-9798-E0BD11ED7D3E", "numeratorUuid": "8C4B62DB-A300-4FAC-ACE1-9DBADC125338", "denominatorExceptionUuid": "F46DADC8-C8A8-4CDD-8599-07B771C60DD5" } } ], "eMeasureUuid": "40280382-6258-7581-0162-8cfbf64110c1" }, { "title": "Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)", "eMeasureId": "CMS144v7", "nqfEMeasureId": "0083e", "nqfId": "0083", "measureId": "008", "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": "Effective Clinical Care", "measureType": "process", "primarySteward": "Physician Consortium for Performance Improvement", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "familyMedicine", 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< 40% who were prescribed beta-blocker therapy at each hospital discharge", "eMeasureUuids": { "initialPopulationUuid": "F7EE681D-64D5-48BB-9F93-D88A36A24647", "denominatorUuid": "68E9F779-6446-4FE1-A120-4CF69F1F782B", "numeratorUuid": "973E2DFA-192A-474E-A963-A93D691380B3", "denominatorExceptionUuid": "9BDB3B97-C1C7-4F35-9BA0-A354C204369B" } } ] }, { "title": "Anti-Depressant Medication Management", "eMeasureId": "CMS128v7", "nqfEMeasureId": null, "nqfId": "0105", "measureId": "009", "description": "Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. 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Prescription Start Date.", "eMeasureUuids": { "initialPopulationUuid": "D040D054-4927-4D01-BC57-F810953D2829", "denominatorUuid": "0CCC6796-3957-4921-9DAA-C35169A3A7AB", "numeratorUuid": "E93F4D1A-F0BD-4F3E-A731-7F569B2467CB", "denominatorExclusionUuid": "7D73AE83-6F35-48B6-94B4-4D5C26475599" }, "name": ">=84Days" }, { "description": "Patients who have received antidepressant medications for at least 180 days (6 months) of continuous treatment during the 231-day period following the Index Prescription Start Date.", "eMeasureUuids": { "initialPopulationUuid": "F7243F23-FA80-4FCC-A4E4-F23A430F19E4", "denominatorUuid": "9DFB4D33-98B4-490B-8A9D-30029F5A6113", "numeratorUuid": "731C990A-340C-49D4-A87B-A7C3B839860D", "denominatorExclusionUuid": "9AB4EA72-C8A9-4975-84DD-3A26CFE64FAE" }, "name": ">=180Days" } ], "eMeasureUuid": "40280382-6258-7581-0162-92901c56156e" }, { "title": "Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation", "eMeasureId": "CMS143v7", "nqfEMeasureId": null, 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"S92.252B", "S92.253A", "S92.253B", "S92.254A", "S92.254B", "S92.255A", "S92.255B", "S92.256A", "S92.256B", "S92.301A", "S92.301B", "S92.302A", "S92.302B", "S92.309A", "S92.309B", "S92.311A", "S92.311B", "S92.312A", "S92.312B", "S92.313A", "S92.313B", "S92.314A", "S92.314B", "S92.315A", "S92.315B", "S92.316A", "S92.316B", "S92.321A", "S92.321B", "S92.322A", "S92.322B", "S92.323A", "S92.323B", "S92.324A", "S92.324B", "S92.325A", "S92.325B", "S92.326A", "S92.326B", "S92.331A", "S92.331B", "S92.332A", "S92.332B", "S92.333A", "S92.333B", "S92.334A", "S92.334B", "S92.335A", "S92.335B", "S92.336A", "S92.336B", "S92.341A", "S92.341B", "S92.342A", "S92.342B", "S92.343A", "S92.343B", "S92.344A", "S92.344B", "S92.345A", "S92.345B", "S92.346A", "S92.346B", "S92.351A", "S92.351B", "S92.352A", "S92.352B", "S92.353A", "S92.353B", "S92.354A", "S92.354B", "S92.355A", "S92.355B", "S92.356A", "S92.356B", "S92.811A", "S92.811B", "S92.812A", "S92.812B", "S92.819A", "S92.819B", "S92.901A", "S92.901B", "S92.902A", "S92.902B", "S92.909A", "S92.909B", "S99.001A", "S99.001B", "S99.002A", "S99.002B", "S99.009A", "S99.009B", "S99.011A", "S99.011B", "S99.012A", "S99.012B", "S99.019A", "S99.019B", "S99.021A", "S99.021B", "S99.022A", "S99.022B", "S99.029A", "S99.029B", "S99.031A", "S99.031B", "S99.032A", "S99.032B", "S99.039A", "S99.039B", "S99.041A", "S99.041B", "S99.042A", "S99.042B", "S99.049A", "S99.049B", "S99.091A", "S99.091B", "S99.092A", "S99.092B", "S99.099A", "S99.099B", "S99.101A", "S99.101B", "S99.102A", "S99.102B", "S99.109A", "S99.109B", "S99.111A", "S99.111B", "S99.112A", "S99.112B", "S99.119A", "S99.119B", "S99.121A", "S99.121B", "S99.122A", "S99.122B", "S99.129A", "S99.129B", "S99.131A", "S99.131B", "S99.132A", "S99.132B", "S99.139A", "S99.139B", "S99.141A", "S99.141B", "S99.142A", "S99.142B", "S99.149A", "S99.149B", "S99.191A", "S99.191B", "S99.192A", "S99.192B", "S99.199A", "S99.199B" ], "minAge": 50, "procedureCodes": [ { "code": "22310" }, { "code": "22315" }, { "code": "22318" }, { "code": "22319" }, { "code": "22325" }, { "code": "22326" }, { "code": "22327" }, { "code": "22510" }, { "code": "22511" }, { "code": "22513" }, { "code": "22514" }, { "code": "25600" }, { "code": "25605" }, { "code": "25606" }, { "code": "25607" }, { "code": "25608" }, { "code": "25609" }, { "code": "27230" }, { "code": "27232" }, { "code": "27235" }, { "code": "27236" }, { "code": "27238" }, { "code": "27240" }, { "code": "27244" }, { "code": "27245" }, { "code": "27246" }, { "code": "27248" } ] } ], "performanceOptions": [ { "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9688" } ] }, { "optionType": "performanceMet", "qualityCodes": [ { "code": "5015F", "modifierExclusions": [ "1P", "2P", "3P", "8P" ] } ] }, { "optionType": "performanceNotMet", "qualityCodes": [ { "code": "5015F", "modifierExclusions": [ "1P", "2P", "3P" ], "modifiers": [ "8P" ] } ] } ] }, { "title": "Screening for Osteoporosis for Women Aged 65-85 Years of Age", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0046", "measureId": "039", "description": "Percentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "claims", "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "preventiveMedicine", "rheumatology", "geriatrics" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_039_MIPSCQM.pdf", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2019_Measure_039_MedicarePartBClaims.pdf" }, "eligibilityOptions": [ { "diagnosisExclusionCodes": [ "M80.00XA", "M80.00XD", "M80.00XG", "M80.00XK", "M80.00XP", "M80.00XS", "M80.011A", "M80.011D", "M80.011G", "M80.011K", "M80.011P", "M80.011S", "M80.012A", "M80.012D", "M80.012G", "M80.012K", "M80.012P", "M80.012S", "M80.019A", "M80.019D", "M80.019G", "M80.019K", "M80.019P", "M80.019S", "M80.021A", "M80.021D", "M80.021G", "M80.021K", "M80.021P", "M80.021S", "M80.022A", "M80.022D", "M80.022G", "M80.022K", "M80.022P", "M80.022S", "M80.029A", "M80.029D", "M80.029G", "M80.029K", "M80.029P", "M80.029S", "M80.031A", "M80.031D", "M80.031G", "M80.031K", "M80.031P", "M80.031S", "M80.032A", "M80.032D", "M80.032G", "M80.032K", "M80.032P", "M80.032S", "M80.039A", "M80.039D", "M80.039G", "M80.039K", "M80.039P", "M80.039S", "M80.041A", "M80.041D", "M80.041G", "M80.041K", "M80.041P", "M80.041S", "M80.042A", "M80.042D", "M80.042G", "M80.042K", "M80.042P", "M80.042S", "M80.049A", "M80.049D", "M80.049G", "M80.049K", "M80.049P", "M80.049S", "M80.051A", "M80.051D", "M80.051G", "M80.051K", "M80.051P", "M80.051S", "M80.052A", "M80.052D", "M80.052G", "M80.052K", "M80.052P", "M80.052S", "M80.059A", "M80.059D", "M80.059G", "M80.059K", "M80.059P", "M80.059S", "M80.061A", "M80.061D", "M80.061G", "M80.061K", "M80.061P", "M80.061S", "M80.062A", "M80.062D", "M80.062G", "M80.062K", "M80.062P", "M80.062S", "M80.069A", "M80.069D", "M80.069G", "M80.069K", "M80.069P", "M80.069S", "M80.071A", "M80.071D", "M80.071G", "M80.071K", "M80.071P", "M80.071S", "M80.072A", "M80.072D", "M80.072G", "M80.072K", "M80.072P", "M80.072S", "M80.079A", "M80.079D", "M80.079G", "M80.079K", "M80.079P", "M80.079S", "M80.08XA", "M80.08XD", "M80.08XG", "M80.08XK", "M80.08XP", "M80.08XS", "M80.80XA", "M80.80XD", "M80.80XG", "M80.80XK", "M80.80XP", "M80.80XS", "M80.811A", "M80.811D", "M80.811G", "M80.811K", "M80.811P", "M80.811S", "M80.812A", "M80.812D", "M80.812G", "M80.812K", "M80.812P", "M80.812S", "M80.819A", "M80.819D", "M80.819G", "M80.819K", "M80.819P", "M80.819S", "M80.821A", "M80.821D", "M80.821G", "M80.821K", "M80.821P", "M80.821S", "M80.822A", "M80.822D", "M80.822G", "M80.822K", "M80.822P", "M80.822S", "M80.829A", "M80.829D", "M80.829G", "M80.829K", "M80.829P", "M80.829S", "M80.831A", "M80.831D", "M80.831G", "M80.831K", "M80.831P", "M80.831S", "M80.832A", "M80.832D", "M80.832G", "M80.832K", "M80.832P", "M80.832S", "M80.839A", "M80.839D", "M80.839G", "M80.839K", "M80.839P", "M80.839S", "M80.841A", "M80.841D", "M80.841G", "M80.841K", "M80.841P", "M80.841S", "M80.842A", "M80.842D", "M80.842G", "M80.842K", "M80.842P", "M80.842S", "M80.849A", "M80.849D", "M80.849G", "M80.849K", "M80.849P", "M80.849S", "M80.851A", "M80.851D", "M80.851G", "M80.851K", "M80.851P", "M80.851S", "M80.852A", "M80.852D", "M80.852G", "M80.852K", "M80.852P", "M80.852S", "M80.859A", "M80.859D", "M80.859G", "M80.859K", "M80.859P", "M80.859S", "M80.861A", "M80.861D", "M80.861G", "M80.861K", "M80.861P", "M80.861S", "M80.862A", "M80.862D", "M80.862G", "M80.862K", "M80.862P", "M80.862S", "M80.869A", "M80.869D", "M80.869G", "M80.869K", "M80.869P", "M80.869S", "M80.871A", "M80.871D", "M80.871G", "M80.871K", "M80.871P", "M80.871S", "M80.872A", "M80.872D", "M80.872G", "M80.872K", "M80.872P", "M80.872S", "M80.879A", "M80.879D", "M80.879G", "M80.879K", "M80.879P", "M80.879S", "M80.88XA", "M80.88XD", "M80.88XG", "M80.88XK", "M80.88XP", "M80.88XS", "M81.0", "M81.6", "M81.8" ], "maxAge": 85, "minAge": 65, "procedureCodes": [ { "code": "99201" }, { "code": "99202" }, { "code": "99203" }, { "code": "99204" }, { "code": "99205" }, { "code": "99212" }, { "code": "99213" }, { "code": "99214" }, { "code": "99215" } ], "sexCode": "F" } ], "performanceOptions": [ { "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9690" } ] }, { "optionType": "performanceMet", "qualityCodes": [ { "code": "G8399" } ] }, { "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8400" } ] } ] }, { "title": "Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0236", "measureId": "044", "description": "Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_044_MIPSCQM.pdf" } }, { "title": "Medication Reconciliation Post-Discharge", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0097", "measureId": "046", "description": "The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years of age 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 recordThis measure is submitted as three rates stratified by age group:- Submission Criteria 1: 18-64 years of age- Submission Criteria 2: 65 years and older- Total Rate: All patients 18 years of age and older", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "overallAlgorithm": "overallStratumOnly", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "claims", "registry" ], "measureSets": [ "orthopedicSurgery", "generalSurgery", "nephrology", "geriatrics" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_046_MIPSCQM.pdf", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2019_Measure_046_MedicarePartBClaims.pdf" }, "strata": [ { "name": "18-64", "description": "Medication Reconciliation Post-Discharge: 18-64 years of age" }, { "name": "65+", "description": "Medication Reconciliation Post-Discharge: 65 years and older" }, { "name": "overall", "description": "Medication Reconciliation Post-Discharge:All patients 18 years of age and older" } ], "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" } ] }, { "minAge": 65, "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" } ] }, { "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" } ] } ], "performanceOptions": [ { "optionType": "performanceMet", "qualityCodes": [ { "code": "1111F", "modifierExclusions": [ "1P", "2P", "3P", "8P" ] } ] }, { 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"category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "pediatrics", "infectiousDisease" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_205_MIPSCQM.pdf" } }, { "title": "Functional Status Change for Patients with Knee Impairments", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0422", "measureId": "217", "description": "A patient-reported outcome measure of risk-adjusted change in functional status for patients aged 14 years+ with knee impairments. The change in functional status (FS) is assessed using the Knee FS patient-reported outcome measure (PROM) (©Focus on Therapeutic Outcomes, Inc.). The 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. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "patientReportedOutcome", "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_217_MIPSCQM.pdf" } }, { "title": "Functional Status Change for Patients with Hip Impairments", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0423", "measureId": "218", "description": "A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with hip impairments. The change in functional status (FS) is assessed using the Hip FS patient-reported outcome measure (PROM) (©Focus on Therapeutic Outcomes, Inc.). The 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. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "patientReportedOutcome", "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_218_MIPSCQM.pdf" } }, { "title": "Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0424", "measureId": "219", "description": "A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with foot, ankle and lower leg impairments. The change in functional status (FS) assessed using the Foot/Ankle FS patient-reported outcome measure (PROM) (©Focus on Therapeutic Outcomes, Inc.). The 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. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "patientReportedOutcome", "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_219_MIPSCQM.pdf" } }, { "title": "Functional Status Change for Patients with Low Back Impairments", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0425", "measureId": "220", "description": "A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with low back impairments. The change in functional status (FS) is assessed using the Low Back FS patient-reported outcome measure (PROM) (©Focus on Therapeutic Outcomes, Inc.). The 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. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "patientReportedOutcome", "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_220_MIPSCQM.pdf" } }, { "title": "Functional Status Change for Patients with Shoulder Impairments", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0426", "measureId": "221", "description": "A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with shoulder impairments. The change in functional status (FS) is assessed using the Shoulder FS patient-reported outcome measure (PROM) (©Focus on Therapeutic Outcomes, Inc.).The 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. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "patientReportedOutcome", "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_221_MIPSCQM.pdf" } }, { "title": "Functional Status Change for Patients with Elbow, Wrist or Hand Impairments", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0427", "measureId": "222", "description": "A patient-reported outcome measure of risk-adjusted change in functional status (FS) for patients 14 years+ with elbow, wrist or hand impairments. The change in FS is assessed using the Elbow/Wrist/Hand FS patient-reported outcome measure (PROM) (©Focus on Therapeutic Outcomes, Inc.) The 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. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "patientReportedOutcome", "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_222_MIPSCQM.pdf" } }, { "title": "Functional Status Change for Patients with General Orthopedic Impairments", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0428", "measureId": "223", "description": "A patient-reported outcome measure of risk-adjusted change in functional status (FS) for patients aged 14 years+ with general orthopedic impairments (neck, cranium, mandible, thoracic spine, ribs or other general orthopedic impairment). The change in FS is assessed using the General Orthopedic FS PROM (patient reported outcome measure) (©Focus on Therapeutic Outcomes, Inc.). The 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. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "patientReportedOutcome", "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_223_MIPSCQM.pdf" } }, { "title": "Radiology: Reminder System for Screening Mammograms", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0509", "measureId": "225", "description": "Percentage of patients undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "structure", "primarySteward": "American College of Radiology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "claims", "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_225_MIPSCQM.pdf", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2019_Measure_225_MedicarePartBClaims.pdf" }, "eligibilityOptions": [ { "diagnosisCodes": [ "Z12.31" ], "minAge": 0, "procedureCodes": [ { "code": "77067" } ] } ], "performanceOptions": [ { "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "7025F", "modifierExclusions": [ "2P", "3P", "8P" ], "modifiers": [ "1P" ] } ] }, { "optionType": "performanceMet", "qualityCodes": [ { "code": "7025F", "modifierExclusions": [ "1P", "2P", "3P", "8P" ] } ] }, { "optionType": "performanceNotMet", "qualityCodes": [ { "code": "7025F", "modifierExclusions": [ "1P", "2P", "3P" ], "modifiers": [ "8P" ] } ] } ] }, { "title": "Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention", "eMeasureId": "CMS138v7", "nqfEMeasureId": null, "nqfId": "0028", "measureId": "226", "description": "Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "primarySteward": "Physician Consortium for Performance Improvement", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "overallAlgorithm": "overallStratumOnly", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "claims", "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "gastroenterology", "dermatology", "familyMedicine", "internalMedicine", "obstetricsGynecology", "ophthalmology", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "plasticSurgery", "preventiveMedicine", "neurology", "mentalBehavioralHealth", "vascularSurgery", "generalSurgery", "thoracicSurgery", "urology", "oncology", "rheumatology", "neurosurgical", "podiatry", "urgentCare" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_226_MIPSCQM.pdf", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2019_Measure_226_MedicarePartBClaims.pdf", "cmsWebInterface": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Web-Interface-Measures/2019_Measure_PREV10_CMSWebInterface_UPDATES.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2019/cms138v7" }, "strata": [ { "name": "screenedForUse", "description": "Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months", "eMeasureUuids": { "initialPopulationUuid": "D03DA272-DBB3-4F46-B19B-CF3262A23C2E", "denominatorUuid": "0F1384E0-350D-43B9-8C17-1140837F342E", "numeratorUuid": "1356052C-4C82-4859-85B4-D04ACF269564", "denominatorExceptionUuid": "A8DBEC91-05EF-4897-80E4-39400B23F030" } }, { "name": "overall", "description": "Percentage of patients aged 18 years and 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"eligibilityOptions": [ { "minAge": 18, "procedureCodes": [ { "code": "90791", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "90792", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "90832", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "90834", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "90837", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "90845", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "92002" }, { "code": "92004" }, { "code": "92012" }, { "code": "92014" }, { "code": "92521" }, { "code": "92522" }, { "code": "92523" }, { "code": "92524" }, { "code": "92540" }, { "code": "92557" }, { "code": "92625" }, { "code": "96150", "modifierExclusions": [ "GQ", "GT", "95" ], 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recommendations for management in the last 12 months", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "neurology", "mentalBehavioralHealth", "geriatrics" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_283_MIPSCQM.pdf" } }, { "title": "Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "286", "description": "Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "neurology", "mentalBehavioralHealth", "geriatrics" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_286_MIPSCQM.pdf" } }, { "title": "Dementia: Education and Support of Caregivers for Patients with Dementia", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "288", "description": "Percentage of patients with dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND were referred to additional resources for support in the last 12 months", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "neurology", "mentalBehavioralHealth", "geriatrics" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_288_MIPSCQM.pdf" } }, { "title": "Parkinson's Disease: Psychiatric Symptoms Assessment for Patients with Parkinson's Disease", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "290", "description": "Percentage of all patients with a diagnosis of Parkinson's Disease [PD] who were assessed for psychiatric symptoms in the past 12 months", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_290_MIPSCQM.pdf" } }, { "title": "Parkinson's Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson's Disease", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "291", "description": "Percentage of all patients with a diagnosis of Parkinson's Disease [PD] who were assessed for cognitive impairment or dysfunction in the past 12 months", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_291_MIPSCQM.pdf" } }, { "title": "Parkinson's Disease: Rehabilitative Therapy Options", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "293", "description": "Percentage of all patients with a diagnosis of Parkinson's Disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (i.e., physical, occupational, and speech therapy) discussed in the past 12 months", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_293_MIPSCQM.pdf" } }, { "title": "Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "303", "description": "Percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery, based on completing a pre-operative and post-operative visual function survey", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientReportedOutcome", "primarySteward": "American Academy of Ophthalmology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_303_MIPSCQM.pdf" } }, { "title": "Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "304", "description": "Percentage of patients aged 18 years and older who had cataract surgery and were satisfied with their care within 90 days following the cataract surgery, based on completion of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientReportedOutcome", "primarySteward": "American Academy of Ophthalmology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_304_MIPSCQM.pdf" } }, { "title": "Initiation and Engagement of Alcohol and Other Drug Dependence Treatment", "eMeasureId": "CMS137v7", "nqfEMeasureId": null, "nqfId": "0004", "measureId": "305", "description": "Percentage of patients 13 years of age and older with a new episode of alcohol or other drug abuse or (AOD) dependence who received the following. Two rates are reported. a. Percentage of patients who initiated treatment within 14 days of the diagnosis b. Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "overallAlgorithm": "simpleAverage", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2019/cms137v7" }, "strata": [ { "description": "Patients who initiated treatment within 14 days of the diagnosis", "eMeasureUuids": { "initialPopulationUuid": "452021F9-5466-45A8-9528-0F92E70C95DD", "denominatorUuid": "39C79E71-7369-46C3-AD5F-1C5D83BA474A", "numeratorUuid": "22DE67FC-79C0-4725-BDE3-3C9B0A1ACAF7", "denominatorExclusionUuid": "B0687FEA-DC33-40B2-95F7-279E11E3AB28", "strata": [ "F7764C47-6BAE-4359-A3DF-9C452DC95A33", "44729C98-B535-4C78-8BC3-A716323B9965" ] }, "name": "14DaysOfDiagnosis" }, { "description": "Patients who initiated treatment and who had two or more additional services with an alcohol, opioid, or other drug abuse or dependence diagnosis within 30 days of the initiation visit", "eMeasureUuids": { "initialPopulationUuid": "C7127400-8034-45D1-8227-6C244349AB6E", "denominatorUuid": "B636C467-23C5-4A23-8709-C71641B1A3AE", "numeratorUuid": "C3D3C7F3-CADA-45E9-A5AA-A05A3C04A76A", "denominatorExclusionUuid": "089CFF04-2838-4B37-8BDA-647E7B94C709", "strata": [ "2A93884C-D881-447F-BA9B-F2EA0A2F30F4", "7ECED382-8389-4028-9623-36ED3537E010" ] }, "name": "30DaysOfVisit" } ], "eMeasureUuid": "40280382-6258-7581-0162-92a37a9b15df", "cpcPlusGroup": "Other_Measure" }, { "title": "Cervical Cancer Screening", "eMeasureId": "CMS124v7", "nqfEMeasureId": null, "nqfId": "0032", "measureId": "309", "description": "Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:* Women age 21-64 who had cervical cytology performed every 3 years* Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine", "obstetricsGynecology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2019/cms124v7" }, "eMeasureUuid": "40280382-6258-7581-0162-92660f2414b9", "strata": [ { "description": "Women with one or more screenings for cervical cancer. Appropriate screenings are defined by any one of the following criteria:\n\n- Cervical cytology performed during the measurement period or the two years prior to the measurement period for women who are at least 21 years old at the time of the test\n \n- Cervical cytology/human papillomavirus (HPV) co-testing performed during the measurement period or the four years prior to the measurement period for women who are at least 30 years old at the time of the test", "eMeasureUuids": { "initialPopulationUuid": "CC6370F0-F018-412A-97C1-D4979EEBF5A4", "denominatorUuid": "1F51C21F-CE89-46BE-B306-A8D1A8B18442", "numeratorUuid": "58569B1E-E97B-4733-BC6A-1AF476D2721C", "denominatorExclusionUuid": "CED31130-5537-4E93-9AE7-DE8DABA70A9E" } } ], "cpcPlusGroup": "Other_Measure" }, { "title": "Chlamydia Screening for Women", "eMeasureId": "CMS153v7", "nqfEMeasureId": null, "nqfId": "0033", "measureId": "310", "description": "Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "obstetricsGynecology", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2019/cms153v7" }, "eMeasureUuid": "40280382-6258-7581-0162-97958ac818e6", "strata": [ { "description": "Women with at least one chlamydia test during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "74AD1F30-A634-433F-A963-41A64ECA9826", "denominatorUuid": "687CDBAD-DDA9-40AC-A60A-6DD530DCAF3A", "numeratorUuid": "D541817E-208C-43E0-A55D-D574700525D2", "denominatorExclusionUuid": "BDE65498-086A-43E4-BEBB-9F283C16EBB4", "strata": [ "483E377C-4DCD-4CDF-83F7-E85E39402511", "124EF6DD-FEBC-4717-AB0F-03E9E4464EF3" ] } } ] }, { "title": "Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented", "eMeasureId": "CMS22v7", "nqfEMeasureId": null, "nqfId": null, "measureId": "317", "description": "Percentage of patients aged 18 years and older seen during the submitting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "gastroenterology", "dermatology", "emergencyMedicine", "familyMedicine", "internalMedicine", "obstetricsGynecology", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "plasticSurgery", "preventiveMedicine", "neurology", "mentalBehavioralHealth", "vascularSurgery", "generalSurgery", "thoracicSurgery", "urology", "oncology", "rheumatology", "nephrology", "urgentCare", "skilledNursingFacility" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_317_MIPSCQM.pdf", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2019_Measure_317_MedicarePartBClaims.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2019/cms022v7" }, "eMeasureUuid": "40280382-610b-e7a4-0161-9a3a392c37d5", "strata": [ { "description": "Patients who were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated if the blood pressure is pre-hypertensive or hypertensive", "eMeasureUuids": { "initialPopulationUuid": "D019FA53-2049-43D9-B006-E4AB7DA01878", "denominatorUuid": "75FDA064-6A0C-463E-84B2-B307A1F8959F", "numeratorUuid": "54790C8F-7C20-4261-B895-39E915B73F42", "denominatorExceptionUuid": "0EA1313C-BCF6-4526-9AD6-365E8A400805", "denominatorExclusionUuid": "72097A3E-8090-486C-ABCD-9419C9A04291" } } ], "eligibilityOptions": [ { "minAge": 18, "procedureCodes": [ { "code": "90791", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "90792", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "92002" }, { "code": "92004" }, { "code": "92012" }, { "code": "92014" }, { "code": "99201", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99202", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99203", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99204", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99205", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99212", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99213", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99214", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99215", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99236" }, { "code": "99281" }, { "code": "99282" }, { "code": "99283" }, { "code": "99284" }, { "code": "99285" }, { "code": "99304" }, { "code": "99305" }, { "code": "99306" }, { "code": "99307", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99308", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99309", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99310", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99315" }, { "code": "99316" }, { "code": "99318" }, { "code": "99324" }, { "code": "99325" }, { "code": "99326" }, { "code": "99327" }, { "code": "99328" }, { "code": "99334" }, { "code": "99335" }, { "code": "99336" }, { "code": "99337" }, { "code": "99339" }, { "code": "99340" }, { "code": "99341" }, { "code": "99342" }, { "code": "99343" }, { "code": "99344" }, { "code": "99345" }, { "code": "99347" }, { "code": "99348" }, { "code": "99349" }, { "code": "99350" }, { "code": "99385" }, { "code": "99386" }, { "code": "99387" }, { "code": "99395" }, { "code": "99396" }, { "code": "99397" }, { "code": "D7140" }, { "code": "D7210" }, { "code": "G0101" }, { "code": "G0402" }, { "code": "G0438" }, { "code": "G0439" } ] } ], "performanceOptions": [ { "optionType": "performanceMet", "qualityCodes": [ { "code": "G8783" } ] }, { "optionType": "performanceMet", "qualityCodes": [ { "code": "G8950" } ] }, { "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8785" } ] }, { "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8952" } ] }, { "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9744" } ] }, { "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "G9745" } ] } ] }, { "title": "Falls: Screening for Future Fall Risk", "eMeasureId": "CMS139v7", "nqfEMeasureId": null, "nqfId": "0101", "measureId": "318", "description": "Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "cmsWebInterface" ], "measureSets": [ "familyMedicine", "internalMedicine", "orthopedicSurgery", "nephrology", "podiatry" ], "measureSpecification": { "cmsWebInterface": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Web-Interface-Measures/2019_Measure_CARE2_CMSWebInterface_UPDATED.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2019/cms139v7" }, "eMeasureUuid": "40280382-6258-7581-0162-9208ce991364", "strata": [ { "description": "Patients who were screened for future fall risk at least once within the measurement period", "eMeasureUuids": { "initialPopulationUuid": "6BB57058-1BA6-4CC8-82A0-36DDE72E01D3", "denominatorUuid": "8586069F-F8C7-44C1-B3A6-1078F5F5936E", "numeratorUuid": "726DED9F-9CBC-4FEE-B261-4AB16657126D", "denominatorExclusionUuid": "794FFEE9-6FB6-4DF7-A723-9BABEDEA8E23" } } ], "cpcPlusGroup": "Other_Measure" }, { "title": "Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0658", "measureId": "320", "description": "Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomywho had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "American Gastroenterological Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "claims", "registry" ], "measureSets": [ "gastroenterology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_320_MIPSCQM.pdf", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2019_Measure_320_MedicarePartBClaims.pdf" }, "eligibilityOptions": [ { "diagnosisCodes": [ "Z12.11" ], "maxAge": 75, "minAge": 50, "procedureCodes": [ { "code": "44388", "modifierExclusions": [ "52", "53", "73", "74" ] }, { "code": "45378", "modifierExclusions": [ "52", "53", "73", "74" ] }, { "code": "G0121", "modifierExclusions": [ "52", "53", "73", "74" ] } ] } ], "performanceOptions": [ { "optionType": "performanceMet", "qualityCodes": [ { "code": "0528F", "modifierExclusions": [ "1P", "2P", "3P", "8P" ] } ] }, { "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "0528F", "modifierExclusions": [ "2P", "3P", "8P" ], "modifiers": [ "1P" ] } ] }, { "optionType": "performanceNotMet", "qualityCodes": [ { "code": "0528F", "modifierExclusions": [ "1P", "2P", "3P" ], "modifiers": [ "8P" ] } ] } ] }, { "title": "CAHPS for MIPS Group Survey", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0005 & 0006", "measureId": "321", "description": "The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Group Survey is comprised of 10 Summary Survey Measures (SSMs) and measures patient experience of care within a group practice. The NQF endorsement status and endorsement id (if applicable) for each SSM utilized in this measure are as follows: - Getting timely care, appointments, and information;- How well providers Communicate;- Patient's Rating of Provider;- Access to Specialists;- Health Promotion & Education;- Shared Decision Making;- Health Status/Functional Status;- Courteous and Helpful Office Staff;- Care Coordination; and- Stewardship of Patient Resources", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientEngagementExperience", "primarySteward": "Agency for Healthcare Research & Quality", "metricType": "cahps", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "familyMedicine", "internalMedicine" ], "measureSpecification": {} }, { "title": "Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "322", "description": "Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low-risk surgery patients 18 years or older for preoperative evaluation during the 12-month submission period", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "primarySteward": "American College of Cardiology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "cardiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_322_MIPSCQM.pdf" } }, { "title": "Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "323", "description": "Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular 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": "Efficiency and Cost Reduction", "measureType": "efficiency", "primarySteward": "American College of Cardiology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "cardiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_323_MIPSCQM.pdf" } }, { "title": "Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "324", "description": "Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "primarySteward": "American College of Cardiology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "cardiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_324_MIPSCQM.pdf" } }, { "title": "Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "325", "description": "Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "American Psychiatric Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "mentalBehavioralHealth" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_325_MIPSCQM.pdf" } }, { "title": "Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1525", "measureId": "326", "description": "Percentage of patients aged 18 years and older with nonvalvular atrial fibrillation (AF) or atrial flutter who were prescribed warfarin OR another FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American College of Cardiology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": true, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "claims", "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "skilledNursingFacility" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_326_MIPSCQM.pdf", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2019_Measure_326_MedicarePartBClaims.pdf" }, "eligibilityOptions": [ { "diagnosisCodes": [ "I48.0", "I48.1", "I48.2", "I48.3", "I48.4", "I48.91", "I48.92" ], "minAge": 18, "procedureCodes": [ { "code": "99201", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99202", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99203", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99204", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99205", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99212", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99213", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99214", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99215", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99281" }, { "code": "99282" }, { "code": "99283" }, { "code": "99284" }, { "code": "99285" }, { "code": "99304" }, { "code": "99305" }, { "code": "99306" }, { "code": "99307", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99308", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99309", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99310", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "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" } ] } ], "performanceOptions": [ { "optionType": "performanceMet", "qualityCodes": [ { "code": "G8967" } ] }, { "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G9928" } ] }, { "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "G8968" } ] }, { "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "G8969" } ] }, { "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "G9927" } ] }, { "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9929" } ] }, { "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9930" } ] }, { "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9931" } ] } ] }, { "title": "Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10g/dL", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1667", "measureId": "328", "description": "Percentage of calendar months within a 12-month period during which patients aged 17 years and younger with a diagnosis of End Stage Renal Disease (ESRD) receiving hemodialysis or peritoneal dialysis have a hemoglobin level < 10 g/dL", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "intermediateOutcome", "primarySteward": "Renal Physicians Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "nephrology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_328_MIPSCQM.pdf" } }, { "title": "Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "329", "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": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "Renal Physicians Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_329_MIPSCQM.pdf" } }, { "title": "Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "330", "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": "Patient Safety", "measureType": "outcome", "primarySteward": "Renal Physicians Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "nephrology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_330_MIPSCQM.pdf" } }, { "title": "Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "331", "description": "Percentage of patients, aged 18 years and older, with a diagnosis of acute viral sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "emergencyMedicine", "familyMedicine", "internalMedicine", "otolaryngology", "urgentCare" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_331_MIPSCQM.pdf" } }, { "title": "Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "332", "description": "Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "emergencyMedicine", "familyMedicine", "internalMedicine", "otolaryngology", "urgentCare" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_332_MIPSCQM.pdf" } }, { "title": "Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "333", "description": "Percentage of patients aged 18 years and older, with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "emergencyMedicine", "familyMedicine", "internalMedicine", "otolaryngology", "urgentCare" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_333_MIPSCQM.pdf" } }, { "title": "Maternity Care: Elective Delivery or Early Induction Without Medical Indication at >= 37 and < 39 Weeks (Overuse)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "335", "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", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_335_MIPSCQM.pdf" } }, { "title": "Maternity Care: Post-Partum Follow-Up and Care Coordination", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "336", "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": "Communication and Care Coordination", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_336_MIPSCQM.pdf" } }, { "title": "Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis on a Biological Immune Response Modifier", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "337", "description": "Percentage of patients, regardless of age, with psoriasis, psoriatic arthritis and rheumatoid arthritis on a biological immune response modifier whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient's history to determine if they have had appropriate management for a recent or prior positive test", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Dermatology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "dermatology", "familyMedicine", "internalMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_337_MIPSCQM.pdf" } }, { "title": "HIV Viral Load Suppression", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2082", "measureId": "338", "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": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "Health Resources and Services Administration", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "familyMedicine", "internalMedicine", "infectiousDisease" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_338_MIPSCQM.pdf" } }, { "title": "HIV Medical Visit Frequency", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2079", "measureId": "340", "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": "Efficiency and Cost Reduction", "measureType": "process", "primarySteward": "Health Resources and Services Administration", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "infectiousDisease" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_340_MIPSCQM.pdf" } }, { "title": "Pain Brought Under Control Within 48 Hours", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "342", "description": "Patients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) who report pain was brought to a comfortable level within 48 hours", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "primarySteward": "National Hospice and Palliative Care Organization", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_342_MIPSCQM.pdf" } }, { "title": "Screening Colonoscopy Adenoma Detection Rate", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "343", "description": "The percentage of patients age 50 years or older with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "American Society for Gastrointestinal Endoscopy", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "gastroenterology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_343_MIPSCQM.pdf" } }, { "title": "Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "344", "description": "Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "Society for Vascular Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_344_MIPSCQM.pdf" } }, { "title": "Rate of Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) Who Are Stroke Free or Discharged Alive", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1543", "measureId": "345", "description": "Percent of asymptomatic patients undergoing CAS who are stroke free while in the hospital or discharged alive following surgery", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "Society for Vascular Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "vascularSurgery", "neurosurgical" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_345_MIPSCQM.pdf" } }, { "title": "Rate of Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) Who Are Stroke Free or Discharged Alive", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1540", "measureId": "346", "description": "Percent of asymptomatic patients undergoing CEA who are stroke free or discharged alive following surgery", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "Society for Vascular Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "vascularSurgery", "neurosurgical" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_346_MIPSCQM.pdf" } }, { "title": "Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Who Are Discharged Alive", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1534", "measureId": "347", "description": "Percent of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) who are discharged alive", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "primarySteward": "Society for Vascular Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_347_MIPSCQM.pdf" } }, { "title": "HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "348", "description": "Patients with physician-specific risk-standardized rates of procedural complications following the first time implantation of an ICD", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "primarySteward": "The Heart Rhythm Society", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "overallAlgorithm": "weightedAverage", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "electrophysiologyCardiacSpecialist" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_348_MIPSCQM.pdf" }, "strata": [ { "name": "30", "description": "Complications or mortality at 30 days" }, { "name": "90", "description": "Complications at 90 days" } ] }, { "title": "Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "350", "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. nonsteroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "American Association of Hip and Knee Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_350_MIPSCQM.pdf" } }, { "title": "Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "351", "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)", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "American Association of Hip and Knee Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_351_MIPSCQM.pdf" } }, { "title": "Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "352", "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": "Patient Safety", "measureType": "process", "primarySteward": "American Association of Hip and Knee Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_352_MIPSCQM.pdf" } }, { "title": "Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "353", "description": "Percentage of patients regardless of age undergoing a total knee replacement whose operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of each prosthetic implant", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "American Association of Hip and Knee Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_353_MIPSCQM.pdf" } }, { "title": "Anastomotic Leak Intervention", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "354", "description": "Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "primarySteward": "American College of Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_354_MIPSCQM.pdf" } }, { "title": "Unplanned Reoperation within the 30 Day Postoperative Period", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "355", "description": "Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "primarySteward": "American College of Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "plasticSurgery", "generalSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_355_MIPSCQM.pdf" } }, { "title": "Unplanned Hospital Readmission within 30 Days of Principal Procedure", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "356", "description": "Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "American College of Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "plasticSurgery", "generalSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_356_MIPSCQM.pdf" } }, { "title": "Surgical Site Infection (SSI)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "357", "description": "Percentage of patients aged 18 years and older who had a surgical site infection (SSI)", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "American College of Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "otolaryngology", "plasticSurgery", "vascularSurgery", "generalSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_357_MIPSCQM.pdf" } }, { "title": "Patient-Centered Surgical Risk Assessment and Communication", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "358", "description": "Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "process", "primarySteward": "American College of Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "otolaryngology", "plasticSurgery", "vascularSurgery", "generalSurgery", "thoracicSurgery", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_358_MIPSCQM.pdf" } }, { "title": "Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "360", "description": "Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "American College of Radiology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_360_MIPSCQM.pdf" } }, { "title": "Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "361", "description": "Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that are submitted to a radiation dose index registry that is capable of collecting at a minimum selected data elements", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "structure", "primarySteward": "American College of Radiology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_361_MIPSCQM.pdf" } }, { "title": "Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "362", "description": "Percentage of final reports for computed tomography (CT) studies performed for all patients, regardless of age, which document that Digital Imaging and Communications in Medicine (DICOM) format image data are available to non-affiliated external healthcare facilities or entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "structure", "primarySteward": "American College of Radiology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_362_MIPSCQM.pdf" } }, { "title": "Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "364", "description": "Percentage of final reports for CT imaging studies with a finding of an incidental pulmonary nodule for patients aged 35 years and older that contain an impression or conclusion that includes a recommended interval and modality for follow-up (e.g., type of imaging or biopsy) or for no follow-up, and source of recommendations (e.g., guidelines such as Fleischner Society, American Lung Association, American College of Chest Physicians)", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "American College of Radiology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_364_MIPSCQM.pdf" } }, { "title": "Follow-Up Care for Children Prescribed ADHD Medication (ADD)", "eMeasureId": "CMS136v8", "nqfEMeasureId": null, "nqfId": "0108", "measureId": "366", "description": "Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "overallAlgorithm": "simpleAverage", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "pediatrics", "mentalBehavioralHealth" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2019/cms136v8" }, "strata": [ { "description": "Patients who had at least one face-to-face visit with a practitioner with prescribing authority within 30 days after the IPSD.", "eMeasureUuids": { "initialPopulationUuid": "F5F4C658-6848-4004-B5B8-AF2C5DC0A1C1", "denominatorUuid": "8184F88D-D587-4DEC-B64C-E222741965D1", "numeratorUuid": "42F25D08-0B43-4388-B256-BA276FDE48B8", "denominatorExclusionUuid": "38CA7B94-B1BC-4B89-8093-BE3C175F0BE1" }, "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": "C6C60AD7-0901-4140-9C55-6870E043D311", "denominatorUuid": "39641D8A-C01D-4AB3-B92A-52C1B94E34CC", "numeratorUuid": "226956ED-22B1-4722-9179-EBD7C4AC9ECC", "denominatorExclusionUuid": "DE032C8E-7AA3-479A-9BCA-9597A80CCAE0" }, "name": "visitAndFollowups" } ], "eMeasureUuid": "40280382-6258-7581-0162-929d3fb415c3" }, { "title": "Depression Remission at Twelve Months", "eMeasureId": "CMS159v7", "nqfEMeasureId": "0710e", "nqfId": "0710", "measureId": "370", "description": "The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "Minnesota Community Measurement", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "overallAlgorithm": "weightedAverage", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "mentalBehavioralHealth", "geriatrics" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_370_MIPSCQM.pdf", "cmsWebInterface": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Web-Interface-Measures/2019_Measure_MH1_CMSWebInterface_UPDATED.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2019/cms159v7" }, "strata": [ { "description": "Percentage of adolescent patients (aged 12-17 years) with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event who reached remission at twelve months as demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9M score of less than 5.", "eMeasureUuids": { "initialPopulationUuid": "28EF715E-00EF-495A-B529-9FEF83EDA5FF", "denominatorUuid": "81429A7D-591D-4EE0-B1E0-AE7A3AA96D56", "numeratorUuid": "F4580E7F-EB6C-42AB-93A8-9AF1A4FD46EE", "denominatorExclusionUuid": "6B6C8B54-B290-4258-BD5A-9B3562036108", "strata": [ "1D836150-AE93-46B1-9432-DACCC20C5CDF", "E4C1A2E2-1959-4BF7-873E-8EB80128C206" ] }, "name": "12-17" }, { "name": "18+", "description": "Percentage of adult patients (aged 18 years or older) with a diagnosis of major depression or dysthymia and aninitial PHQ-9 or PHQ-9M score greater than nine during the index event who reached remission at twelve months as demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9M score of less than 5." } ], "eMeasureUuid": "40280382-6258-7581-0162-626f31a0009e" }, { "title": "Depression Utilization of the PHQ-9 Tool", "eMeasureId": "CMS160v7", "nqfEMeasureId": "0712e", "nqfId": null, "measureId": "371", "description": "The percentage of adolescent patients 12 to 17 years of age and adult patients age 18 and older with the diagnosis of major depression or dysthymia who have a completed PHQ-9 during each applicable 4 month period in which there was a qualifying depression encounter", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "Minnesota Community Measurement", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "overallAlgorithm": "weightedAverage", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine", "mentalBehavioralHealth" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2019/cms160v7" }, "strata": [ { "name": "4MonthsOfEnd", "description": "Office visit, Psych visit, or Face to Face Interaction (No ED) within 4 months of the end of the measurement period that leads to a diagnosis of major depression including remission or dysthymia", "eMeasureUuids": { "initialPopulationUuid": "D00E7D31-7F59-468D-99C6-631D07715E59", "denominatorUuid": "A52E93B8-A2D1-414E-94D0-90155E8FF81F", "numeratorUuid": "539B0A53-F5B0-47CB-887E-392792E9D4ED", "denominatorExclusionUuid": "0830DDCA-C45E-4D80-B359-E69E2F83D7B2", "strata": [ "13406420-1144-4100-9439-ED134656A4FC", "DD7E5C35-6825-496B-A155-A4CBE9056535" ] } }, { "name": "4&8MonthsAfterStart", "description": "Office visit, Psych visit, or Face to Face Interaction (No ED) between 4 and 8 months after the start of the measurement period that leads to a diagnosis of major depression including remission or dysthymia", "eMeasureUuids": { "initialPopulationUuid": "95F5AFA0-CB23-4786-A2E0-0646C0494E4F", "denominatorUuid": "1B9C4359-5DF7-4B6D-ACD8-C12175C67EFD", "numeratorUuid": "92D313A7-3A3D-44EC-8A94-103CC0003A30", "denominatorExclusionUuid": "7889D513-C24C-482F-8C9C-FC31F35E3999", "strata": [ "39B15197-7895-4AFC-B4AA-83DABFF66373", "0416AB91-F7FF-4432-A5D9-77B27F5AE30C" ] } }, { "name": "4MonthsOfStart", "description": "Office visit, Psych visit, or Face to Face Interaction (No ED) within 4 months of the start of the measurement period that leads to a diagnosis of major depression including remission or dysthymia", "eMeasureUuids": { "initialPopulationUuid": "750B4DDA-EC94-4082-9AB4-86824666D808", "denominatorUuid": "2E3A7115-247D-4A0E-918C-AB581E13486A", "numeratorUuid": "9FCE046B-5EF9-4A19-9D22-D3A6518EDA51", "denominatorExclusionUuid": "DE1952F9-9E35-4493-BA65-3F6CD8904059", "strata": [ "1FD9CB54-2485-43C9-A9CB-041E6FE078F0", "B4B269AE-AE95-4FFF-AD3A-0C7F62DC0C72" ] } } ], "eMeasureUuid": "40280382-6258-7581-0162-63106f9201b2", "cpcPlusGroup": "Other_Measure" }, { "title": "Maternal Depression Screening", "eMeasureId": "CMS82v6", "nqfEMeasureId": null, "nqfId": null, "measureId": "372", "description": "The percentage of children who turned 6 months of age during the measurement year, who had a face-to-face visit between the clinician and the child during child's first 6 months, and who had a maternal depression screening for the mother at least once between 0 and 6 months of life", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2019/cms082v6" }, "eMeasureUuid": "40280382-6258-7581-0162-974e086f181e", "strata": [ { "description": "Children with documentation of maternal screening or treatment for postpartum depression for the mother", "eMeasureUuids": { "initialPopulationUuid": "0ABD1F84-09B1-421D-BE08-10F3B2413456", "denominatorUuid": "B484793F-FF58-49CD-9F29-289B5246BF22", "numeratorUuid": "8E82739E-EE2A-4FA3-8593-01754A177BAB" } } ] }, { "title": "Closing the Referral Loop: Receipt of Specialist Report", "eMeasureId": "CMS50v7", "nqfEMeasureId": null, "nqfId": null, "measureId": "374", "description": "Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "gastroenterology", "dermatology", "familyMedicine", "internalMedicine", "obstetricsGynecology", "ophthalmology", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "preventiveMedicine", "neurology", "mentalBehavioralHealth", "interventionalRadiology", "vascularSurgery", "generalSurgery", "thoracicSurgery", "urology", "oncology", "rheumatology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_374_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2019/cms050v7" }, "eMeasureUuid": "40280382-6240-b6b9-0162-5467c36a0b71", "strata": [ { "description": "Number of patients with a referral, for which the referring provider received a report from the provider to whom the patient was referred", "eMeasureUuids": { "initialPopulationUuid": "0229D504-DC16-4B65-B0D4-EFBBEEE290E4", "denominatorUuid": "E666FF2F-A334-4FD8-8374-19087A06961F", "numeratorUuid": "4075E039-7118-460C-9356-D8B329DE183D" } } ], "cpcPlusGroup": "Other_Measure" }, { "title": "Functional Status Assessment for Total Knee Replacement", "eMeasureId": "CMS66v7", "nqfEMeasureId": null, "nqfId": null, "measureId": "375", "description": "Percentage of patients 18 years of age and older who received an elective primary total knee arthroplasty (TKA) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2019/cms066v7" }, "eMeasureUuid": "40280382-6258-7581-0162-9b6651201a04", "strata": [ { "description": "Patients with patient-reported functional status assessment results (i.e., VR-12, PROMIS-10 Global Health, KOOS, KOOS Jr.) in the 90 days prior to or on the day of the primary TKA procedure, and in the 270 - 365 days after the TKA procedure", "eMeasureUuids": { "initialPopulationUuid": "F8EB92AC-C55A-466B-9345-4CD5572B29D6", "denominatorUuid": "2CFF455B-6103-4B2E-A3B3-EAA20AECA766", "numeratorUuid": "E9FCC926-AFB3-4A33-BD7E-656C96E131C1", "denominatorExclusionUuid": "02D4C01D-BDF8-4686-B3B1-486ADB6463C0" } } ] }, { "title": "Functional Status Assessment for Total Hip Replacement", "eMeasureId": "CMS56v7", "nqfEMeasureId": null, "nqfId": null, "measureId": "376", "description": "Percentage of patients 18 years of age and older who received an elective primary total hip arthroplasty (THA) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2019/cms056v7" }, "eMeasureUuid": "40280382-6258-7581-0162-97717ae2188b", "strata": [ { "description": "Patients with patient-reported functional status assessment results (i.e., VR-12, PROMIS-10-Global Health, HOOS, HOOS Jr.) in the 90 days prior to or on the day of the primary THA procedure, and in the 270 - 365 days after THA procedure", "eMeasureUuids": { "initialPopulationUuid": "18FA6F98-08F5-49BD-8909-14AE4EA22420", "denominatorUuid": "B9A584E2-8869-469E-B492-07613B0A6152", "numeratorUuid": "B28BF434-F43C-4982-A7E3-7E52E27E9C1B", "denominatorExclusionUuid": "1282FBA4-2F72-406A-9354-3A1E6E92ADD9" } } ] }, { "title": "Functional Status Assessments for Congestive Heart Failure", "eMeasureId": "CMS90v8", "nqfEMeasureId": null, "nqfId": null, "measureId": "377", "description": "Percentage of patients 18 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessments", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2019/cms090v8" }, "eMeasureUuid": "40280382-6258-7581-0162-9214c9a9139e", "strata": [ { "description": "Patients with patient-reported functional status assessment results (ie, VR-12; VR-36; KCCQ; PROMIS-10 Global Health, PROMIS-29) present in the EHR two weeks before or during the initial FSA encounter and results for the follow-up FSA at least 30 days but no more than 180 days after the initial functional status assessment", "eMeasureUuids": { "initialPopulationUuid": "2CCC4C8A-32E2-4EF3-8EB7-38773DAD3DC4", "denominatorUuid": "52F79D36-2C65-4FD3-8605-9B8E122F54D8", "numeratorUuid": "EC0ED867-67DD-4F6A-9EA8-7B2B4D9BE70B", "denominatorExclusionUuid": "FDADE71D-E911-47BF-A2C0-0FCD3F736AA0" } } ] }, { "title": "Children Who Have Dental Decay or Cavities", "eMeasureId": "CMS75v7", "nqfEMeasureId": null, "nqfId": null, "measureId": "378", "description": "Percentage of children, age 0-20 years, who have had tooth decay or cavities during the measurement period", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "outcome", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "dentistry" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2019/cms075v7" }, "eMeasureUuid": "40280382-6258-7581-0162-930923861702", "strata": [ { "description": "Children who had cavities or decayed teeth", "eMeasureUuids": { "initialPopulationUuid": "E3EAD500-A4F2-45C2-A370-B5C191DC7825", "denominatorUuid": "466991C9-1413-4FDA-9DE5-B1B0A262271B", "numeratorUuid": "007F6693-32AC-43C3-B97D-6DBCA05F9F3E", "denominatorExclusionUuid": "7CAC738B-EEBA-4683-88C6-CF344BF47A87" } } ] }, { "title": "Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists", "eMeasureId": "CMS74v8", "nqfEMeasureId": null, "nqfId": null, "measureId": "379", "description": "Percentage of children, age 0-20 years, who received a fluoride varnish application during the measurement period", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "pediatrics", "dentistry" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2019/cms074v8" }, "eMeasureUuid": "40280382-6258-7581-0162-92fea60316ee", "strata": [ { "description": "Children who receive a fluoride varnish application", "eMeasureUuids": { "initialPopulationUuid": "4DAE1F06-ACAC-4FE8-B2DB-6819D5106076", "denominatorUuid": "8A1CEA1D-8C98-441A-BB1B-2844586B5E82", "numeratorUuid": "A89FFB85-F438-466C-AB5F-7EB31310285B", "denominatorExclusionUuid": "072B2944-36FE-4557-B332-EB91FE97421A", "strata": [ "69C80D2F-2C9D-40CB-B75A-2B29B8C37786", "087992AE-837D-43B9-88C5-EB55BA2E810B", "F4FC32F4-C178-477D-9250-CB60081D5222" ] } } ] }, { "title": "Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment", "eMeasureId": "CMS177v7", "nqfEMeasureId": "1365e", "nqfId": null, "measureId": "382", "description": "Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "Physician Consortium for Performance Improvement", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "pediatrics", "mentalBehavioralHealth" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2019/cms177v7" }, "eMeasureUuid": "40280382-6240-b6b9-0162-54b832d90d52", "strata": [ { "description": "Patient visits with an assessment for suicide risk", "eMeasureUuids": { "initialPopulationUuid": "0F0FB2E3-6F44-4A80-9D8B-B7CD02CC3595", "denominatorUuid": "E008C006-7EA5-4BD8-B6A7-89927F8C9625", "numeratorUuid": "FCE22FCD-291F-4606-93E9-B77588BBF50B" } } ] }, { "title": "Adherence to Antipsychotic Medications For Individuals with Schizophrenia", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1879", "measureId": "383", "description": "Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months)", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "intermediateOutcome", "primarySteward": "Health Services Advisory Group", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "mentalBehavioralHealth" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_383_MIPSCQM.pdf" } }, { "title": "Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "384", "description": "Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "American Academy of Ophthalmology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_384_MIPSCQM.pdf" } }, { "title": "Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "385", "description": "Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "American Academy of Ophthalmology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_385_MIPSCQM.pdf" } }, { "title": "Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "386", "description": "Percentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g. advance directives, invasive ventilation, hospice) at least once annually", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_386_MIPSCQM.pdf" } }, { "title": "Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "387", "description": "Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12-month reporting period", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "Physician Consortium for Performance Improvement", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_387_MIPSCQM.pdf" } }, { "title": "Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "388", "description": "Percentage of patients aged 18 years and older who had cataract surgery performed and had an unplanned rupture of the posterior capsule requiring vitrectomy", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "primarySteward": "American Academy of Ophthalmology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_388_MIPSCQM.pdf" } }, { "title": "Cataract Surgery: Difference Between Planned and Final Refraction", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "389", "description": "Percentage of patients aged 18 years and older who had cataract surgery performed and who achieved a final refraction within +/- 1.0 diopters of their planned (target) refraction", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "American Academy of Ophthalmology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_389_MIPSCQM.pdf" } }, { "title": "Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "390", "description": "Percentage of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or other qualified healthcare professional reviewed the range of treatment options appropriate to their genotype and demonstrated a shared decision making approach with the patient. To meet the measure, there must be documentation in the patient record of a discussion between the physician or other qualified healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "process", "primarySteward": "American Gastroenterological Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "gastroenterology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_390_MIPSCQM.pdf" } }, { "title": "Follow-Up After Hospitalization for Mental Illness (FUH)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0576", "measureId": "391", "description": "The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner. Two rates are submitted: - The percentage of discharges for which the patient received follow-up within 30 days after discharge. - The percentage of discharges for which the patient received follow-up within 7 days after discharge.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "overallAlgorithm": "overallStratumOnly", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "pediatrics", "mentalBehavioralHealth" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_391_MIPSCQM.pdf" }, "strata": [ { "name": "30days", "description": "The percentage of discharges for which the patient received follow-up within 30 days after discharge" }, { "name": "overall", "description": "The percentage of discharges for which the patient received follow-up within 7 days after discharge" } ] }, { "title": "HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2474", "measureId": "392", "description": "Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation This measure is submitted as four rates stratified by age and gender:- Submission Age Criteria 1: Females 18-64 years of age- Submission Age Criteria 2: Males 18-64 years of age- Submission Age Criteria 3: Females 65 years of age and older- Submission Age Criteria 4: Males 65 years of age and older", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "primarySteward": "The Heart Rhythm Society", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "overallAlgorithm": "overallStratumOnly", "isIcdImpacted": true, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "electrophysiologyCardiacSpecialist" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_392_MIPSCQM.pdf" }, "strata": [ { "name": "18-64F", "description": "Females 18-64 years of age" }, { "name": "18-64M", "description": "Males 18-64 years of age" }, { "name": "65+F", "description": "Females 65 years of age and older" }, { "name": "65+M", "description": "Males 65 years of age and older" }, { "name": "overall", "description": "Overall percentage of patients with cardiac tamponade and/or pericardiocentesis occurring within 30 days" } ] }, { "title": "HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "393", "description": "Infection rate following CIED device implantation, replacement, or revision", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "primarySteward": "The Heart Rhythm Society", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "electrophysiologyCardiacSpecialist" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_393_MIPSCQM.pdf" } }, { "title": "Immunizations for Adolescents", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1407", "measureId": "394", "description": "The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "overallAlgorithm": "overallStratumOnly", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "pediatrics" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_394_MIPSCQM.pdf" }, "strata": [ { "name": "meningococcal", "description": "Patients who had one dose of meningococcal vaccine on 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The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include:- Most recent blood pressure (BP) measurement is less than or equal to 140/90 mm Hg -- AND- Most recent tobacco status is Tobacco Free -- AND- Daily Aspirin or Other Antiplatelet Unless Contraindicated -- AND- Statin Use Unless Contraindicated", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "intermediateOutcome", "primarySteward": "Wisconsin Collaborative for Healthcare Quality", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_441_MIPSCQM.pdf" } }, { "title": "Persistence of Beta-Blocker Treatment After a Heart Attack", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0071", "measureId": "442", "description": "The percentage of patients 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with adiagnosis of acute myocardial infarction (AMI) and who were prescribed persistent beta-blocker treatment for six months after discharge", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_442_MIPSCQM.pdf" } }, { "title": "Non-Recommended Cervical Cancer Screening in Adolescent Females", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "443", "description": "The percentage of adolescent females 16-20 years of age who were screened unnecessarily for cervical cancer", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "obstetricsGynecology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_443_MIPSCQM.pdf" } }, { "title": "Medication Management for People with Asthma", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "444", "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": "Efficiency and Cost Reduction", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "pediatrics" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_444_MIPSCQM.pdf" } }, { "title": "Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0119", "measureId": "445", "description": "Percent of patients aged 18 years and older undergoing isolated CABG who die, including both all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "Society of Thoracic Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "thoracicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_445_MIPSCQM.pdf" } }, { "title": "Operative Mortality Stratified by the Five STS-EACTS Mortality Categories", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0733", "measureId": "446", "description": "Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other 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": "Patient Safety", "measureType": "outcome", "primarySteward": "Society of Thoracic Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_446_MIPSCQM.pdf" } }, { "title": "Appropriate Workup Prior to Endometrial Ablation", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "448", "description": "Percentage of women, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results documented before undergoing an endometrial ablation", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "obstetricsGynecology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_448_MIPSCQM.pdf" } }, { "title": "HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1857", "measureId": "449", "description": "Percentage 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": "Efficiency and Cost Reduction", "measureType": "process", "primarySteward": "American Society of Clinical Oncology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_449_MIPSCQM.pdf" } }, { "title": "Trastuzumab Received By Patients With AJCC Stage I (T1c) - III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1858", "measureId": "450", "description": "Percentage 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", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Society of Clinical Oncology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_450_MIPSCQM.pdf" } }, { "title": "RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1859", "measureId": "451", "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 RAS (KRAS and NRAS) gene mutation testing was performed", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Society of Clinical Oncology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_451_MIPSCQM.pdf" } }, { "title": "Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1860", "measureId": "452", "description": "Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer and RAS (KRAS or NRAS) gene mutation spared treatment with anti-EGFR monoclonal antibodies", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "American Society of Clinical Oncology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_452_MIPSCQM.pdf" } }, { "title": "Percentage of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life (lower score - better)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0210", "measureId": "453", "description": "Percentage of patients who died from cancer receiving chemotherapy in the last 14 days of life", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Society of Clinical Oncology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_453_MIPSCQM.pdf" } }, { "title": "Percentage of Patients who Died from Cancer with More than One Emergency Department Visit in the Last 30 Days of Life (lower score - better)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "454", "description": "Percentage of patients who died from cancer with more than one emergency department visit in the last 30 days of life", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "American Society of Clinical Oncology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_454_MIPSCQM.pdf" } }, { "title": "Percentage of Patients Who Died from Cancer Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life (lower score - better)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0213", "measureId": "455", "description": "Percentage of patients who died from cancer admitted to the ICU in the last 30 days of life", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "American Society of Clinical Oncology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "oncology", "geriatrics" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_455_MIPSCQM.pdf" } }, { "title": "Percentage of Patients Who Died From Cancer Not Admitted To Hospice (lower score - better)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0215", "measureId": "456", "description": "Percentage of patients who died from cancer not admitted to hospice", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Society of Clinical Oncology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_456_MIPSCQM.pdf" } }, { "title": "Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score - better)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0216", "measureId": "457", "description": "Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "American Society of Clinical Oncology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_457_MIPSCQM.pdf" } }, { "title": "All-cause Hospital Readmission", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1789", "measureId": "458", "description": "The 30-day All-Cause Hospital Readmission measure is a risk-standardized readmission rate for beneficiaries age 65 or older who were hospitalized at a short-stay acute care hospital and experienced an unplanned readmission for any cause to an acute care hospital within 30 days of discharge", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "primarySteward": "Yale University", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} }, { "title": "Average Change in Back Pain Following Lumbar Discectomy/Laminotomy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "459", "description": "The average change (preoperative to three months postoperative) in back pain for patients 18 years of age or older who had a lumbar discectomy/laminotomy procedure", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientReportedOutcome", "primarySteward": "Minnesota Community Measurement", "metricType": "nonProportion", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "neurosurgical" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_459_MIPSCQM.pdf" } }, { "title": "Average Change in Back Pain Following Lumbar Fusion", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "460", "description": "The average change (preoperative to one year postoperative) in back pain for patients 18 years of age or older who had a lumbar fusion procedure", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientReportedOutcome", "primarySteward": "Minnesota Community Measurement", "metricType": "nonProportion", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "neurosurgical" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_460_MIPSCQM.pdf" } }, { "title": "Average Change in Leg Pain Following Lumbar Discectomy and/or Laminotomy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "461", "description": "The average change (preoperative to three months postoperative) in leg pain for patients 18 years of age or older who had a lumbar discectomy/laminotomy procedure", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientReportedOutcome", "primarySteward": "Minnesota Community Measurement", "metricType": "nonProportion", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "neurosurgical" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_461_MIPSCQM.pdf" } }, { "title": "Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy", "eMeasureId": "CMS645v2", "nqfEMeasureId": null, "nqfId": null, "measureId": "462", "description": "Patients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater (indicated by HCPCS code) and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "Oregon Urology Institute", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "urology", "oncology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2019/cms645v2" }, "eMeasureUuid": "40280382-610b-e7a4-0161-7c19ad7c2a5d", "strata": [ { "description": "Patients with a bone density evaluation within the two years prior to the start of or less than three months after the start of ADT treatment", "eMeasureUuids": { "initialPopulationUuid": "6943043A-E370-49DE-9B16-56E61CE9F062", "denominatorUuid": "F4A7E971-A676-425D-B0BD-1951F3F22407", "numeratorUuid": "4EB0E993-A98D-4E42-8B7E-158BDC19F521", "denominatorExceptionUuid": "84B0E025-DC5A-4B45-BC2E-8B71E64907D4" } } ] }, { "title": "Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "463", "description": "Percentage of patients aged 3 through 17 years, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post-operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperatively", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "American Society of Anesthesiologists", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_463_MIPSCQM.pdf" } }, { "title": "Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0657", "measureId": "464", "description": "Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "otolaryngology", "pediatrics", "infectiousDisease", "urgentCare" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_464_MIPSCQM.pdf" } }, { "title": "Uterine Artery Embolization Technique: Documentation of Angigraphic Endpoints and Interrogation of Ovarian Arteries", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "465", "description": "The percentage of patients with documentation of angiographic endpoints of embolization AND the documentation of embolization strategies in the presence of unilateral or bilateral absent uterine arteries", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "Society of Interventional Radiology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "interventionalRadiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_465_MIPSCQM.pdf" } }, { "title": "Developmental Screening in the First Three Years of Life", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1448", "measureId": "467", "description": "The percentage of children screened for risk of developmental, behavioral and social delays using a standardized screening tool in the 12 months preceding or on their first, second, or third birthday. This is a composite measure of screening in the first three years of life that includes three, age-specific indicators assessing whether children are screened in the 12 months preceding or on their first, second or third birthday", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "primarySteward": "Oregon Health & Science University", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "overallAlgorithm": "overallStratumOnly", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "pediatrics" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_467_MIPSCQM.pdf" }, "strata": [ { "name": "<1", "description": "Children in the eligible population who turned 1 during the performance period. (Birth to 1 year of age) who were screened for risk of developmental, behavioral and social delays using a standardized tool with interpretation and report within 12 months preceding or on their birthday" }, { "name": "1-2", "description": "Children in the eligible population who turned 2 during the performance period (> 1 year to 2 years of age) who were screened for risk of developmental, behavioral and social delays using a standardized tool with interpretation and report within 12 months preceding or on their birthday" }, { "name": "2-3", "description": "Children in the eligible population who turned 3 during the performance period ( > 2 years to 3 years of age) who were screened for risk of developmental, behavioral and social delays using a standardized tool with interpretation and report within 12 months preceding or on their birthday" }, { "name": "overall", "description": "Total Performance Rate based on all children who turned 1, 2, or 3 during the performance period who were screened for risk of developmental, behavioral and social delays using a standardized tool with interpretation and report within 12 months preceding or on their birthday, i.e., the sum of denominators 1, 2, and 3." } ] }, { "title": "Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3175", "measureId": "468", "description": "Percentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "University of Southern California", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "physicalMedicine", "mentalBehavioralHealth" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_468_MIPSCQM.pdf" } }, { "title": "Average Change in Functional Status Following Lumbar Fusion Surgery", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2643", "measureId": "469", "description": "The average change (preoperative to postoperative) in functional status using the Oswestry Disability Index (ODI version 2. 1a) for patients 18 years of age and older who had a lumbar fusion procedure", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientReportedOutcome", "primarySteward": "Minnesota Community Measurement", "metricType": "nonProportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "neurosurgical" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_469_MIPSCQM.pdf" } }, { "title": "Average Change In Functional Status Following Total Knee Replacement Surgery", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2653", "measureId": "470", "description": "The average change (preoperative to postoperative) in functional status using the Oxford Knee Score (OKS) for patients age 18 and older who had a primary total knee replacement", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientReportedOutcome", "primarySteward": "Minnesota Community Measurement", "metricType": "nonProportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_470_MIPSCQM.pdf" } }, { "title": "Average Change in Functional Status Following Lumbar Discectomy/Laminotomy Surgery", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "471", "description": "The average change (preoperative to postoperative) in functional status using the Oswestry Disability Index (ODI version 2.1a) for patients age 18 and older who had lumbar discectomy/laminotomy procedure", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientReportedOutcome", "primarySteward": "Minnesota Community Measurement", "metricType": "nonProportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "neurosurgical" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_471_MIPSCQM.pdf" } }, { "title": "Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture", "eMeasureId": "CMS249v1", "nqfEMeasureId": null, "nqfId": null, "measureId": "472", "description": "Percentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine", "obstetricsGynecology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2019/cms249v1" }, "eMeasureUuid": "40280382-6258-7581-0162-92de53e31699", "strata": [ { "description": "Female patients who received an order for at least one DXA scan in the measurement period", "eMeasureUuids": { "initialPopulationUuid": "14C62E37-7B68-4636-B6D3-65FCFA922B85", "denominatorUuid": "99FEE774-9169-4A52-A890-7175726E40F6", "numeratorUuid": "6E2DF1CA-216E-44CC-8587-AE7D3B743048", "denominatorExclusionUuid": "0FB2B684-8D8D-44C6-9945-0B16543FF95E" } } ] }, { "title": "Average Change in Leg Pain Following Lumbar Fusion Surgery", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "473", "description": "The average change (preoperative to one year postoperative) in leg pain for patients 18 years of age or older who had a lumbar fusion procedure", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientReportedOutcome", "primarySteward": "Minnesota Community Measurement", "metricType": "nonProportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "neurosurgical" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_473_MIPSCQM.pdf" } }, { "title": "Zoster (Shingles) Vaccination", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "474", "description": "The percentage of patients aged 50 years and older who have had the Shingrix zoster (shingles) vaccination.", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "primarySteward": "PPRNet", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "preventiveMedicine", "oncology", "nephrology", "infectiousDisease", "geriatrics", "skilledNursingFacility" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_474_MIPSCQM.pdf" } }, { "title": "HIV Screening", "eMeasureId": "CMS349v1", "nqfEMeasureId": null, "nqfId": null, "measureId": "475", "description": "Percentage of patients 15-65 years of age who have been tested for HIV within that age range", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "primarySteward": "Centers for Disease Control and Prevention", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine", "obstetricsGynecology", "preventiveMedicine", "infectiousDisease" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2019/cms349v1" }, "eMeasureUuid": "40280382-6258-7581-0162-9242b345140c", "strata": [ { "description": "Patients with documentation of an HIV test between age 15-65 before the end of the measurement period", "eMeasureUuids": { "initialPopulationUuid": "B478EA80-2D7B-4F58-A8CD-E2F2BE3E40AA", "denominatorUuid": "0BF35D9B-3766-4FFE-A0B8-20709C608D82", "numeratorUuid": "3678ABF6-E7B9-4926-B3DB-494A4D7972A2", "denominatorExclusionUuid": "E898D041-EDD9-4D7C-9EDA-E2C5D0A76F0C" } } ] }, { "title": "CAHPS for ACOs Group Survey", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "ACO321", "description": "Getting timely care, appointments, and information; How well providers Communicate; Patient's Rating of Provider; Access to Specialists; Health Promotion & Education; Shared Decision Making; Health Status/Functional Status; and Stewardship of Patient Resources", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientEngagementExperience", "primarySteward": "Agency for Healthcare Research & Quality", "metricType": "cahps", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [], "measureSpecification": {} }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": 0, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": "https://qpp.cms.gov/docs/pi_specifications/Measure%20Specifications/2019MIPSPIMeasuresSecurityRiskAnalysis.pdf", "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_ONCDIR_1", "title": "ONC Direct Review Attestation", "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": 0, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_INFBLO_1", "title": "Prevention of Information Blocking Attestation", "description": "I attest to CMS that I - (A) did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology. (B) Implemented technologies, standards, policies, practices, and agreements reasonably calculated to ensure, to the greatest extent practicable and permitted by law, that the certified EHR technology was, at all relevant times: (1) Connected in accordance with applicable law; (2) Compliant with all standards applicable to the exchange of information, including the standards, implementation specifications, and certification criteria adopted at 45 CFR part 170; (3) Implemented in a manner that allowed for timely access by patients to their electronic health information; and (4) Implemented in a manner that allowed for the timely, secure, and trusted bi-directional exchange of structured electronic health information with other health care providers (as defined by 42 U.S.C. 300jj(3)), including unaffiliated health care providers, and with disparate certified EHR technology and vendors. (C) Responded in good faith and in a timely manner to requests to retrieve or exchange electronic health information, including from patients, health care providers (as defined by 42 U.S.C. 300jj(3)), and other persons, regardless of the requestor's affiliation or technology vendor.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": 0, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_ONCACB_1", "title": "ONC-ACB Surveillance Attestation", "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.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": 0, "objective": "attestation", "isBonus": false, "reportingCategory": null, "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_EP_1", "title": "e-Prescribing", "description": "At least one permissible prescription written by the MIPS eligible clinician is queried for a drug formulary and transmitted electronically using CEHRT.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": 10, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": "https://qpp.cms.gov/docs/pi_specifications/Measure%20Specifications/2019MIPSPIMeasuresEPrescribing.pdf", "measureSets": [], "exclusion": "PI_LVPP_1" }, { "category": "pi", "measureId": "PI_LVPP_1", "title": "e-Prescribing Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": 0, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_EP_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP)", "description": "For at least one Schedule II opioid electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a Prescription Drug Monitoring Program (PDMP) for prescription drug history, except where prohibited and in accordance with applicable law.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "weight": 5, "objective": "electronicPrescribing", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": "https://qpp.cms.gov/docs/pi_specifications/Measure%20Specifications/2019MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram(PDMP).pdf", "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_EP_3", "title": "Verify Opioid Treatment Agreement", "description": "For at least one unique patient for whom a Schedule II opioid was electronically prescribed by the MIPS eligible clinician using CEHRT during the performance period, if the total duration of the patient's Schedule II opioid prescriptions is at least 30 cumulative days within a 6-month look-back period, the MIPS eligible clinician seeks to identify the existence of a signed opioid treatment agreement and incorporates it into the patient's electronic health record using CEHRT.", "isRequired": false, "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "weight": 5, "objective": "electronicPrescribing", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": "https://qpp.cms.gov/docs/pi_specifications/Measure%20Specifications/2019MIPSPIMeasuresVerifyOpioidTreatmentAgreement.pdf", "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_HIE_1", "title": "Support Electronic Referral Loops By Sending Health Information", "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 electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": 20, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": "https://qpp.cms.gov/docs/pi_specifications/Measure%20Specifications/2019MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf", "measureSets": [], "exclusion": "PI_LVOTC_1" }, { "category": "pi", "measureId": "PI_LVOTC_1", "title": "Support Electronic Referral Loops By Sending Health Information Exclusion", "description": "Any MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": 0, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_HIE_4", "title": "Support Electronic Referral Loops By Receiving and Incorporating Health Information", "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "weight": 20, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": "https://qpp.cms.gov/docs/pi_specifications/Measure%20Specifications/2019MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandIncorpo.pdf", "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_LVITC_2", "title": "Support Electronic Referral Loops By Receiving and Incorporating Health Information Exclusion", "description": "Any MIPS eligible clinician who receives transitions of care or referrals or has patient encounters in which the MIPS eligible clinician has never before encountered the patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "weight": 0, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_CUITC_1", "title": "Support Electronic Referral Loops By Receiving and Incorporating Health Information Exclusion", "description": "Any MIPS eligible clinician who is unable to implement the measure for a MIPS performance period in 2019 would be excluded from having to report this measure.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "weight": 0, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_PEA_1", "title": "Provide Patients Electronic Access to Their Health Information", "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 electronic health record technology (CEHRT).", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": 40, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": "https://qpp.cms.gov/docs/pi_specifications/Measure%20Specifications/2019MIPSPIMeasuresProvidePatientsElectronicAccesstoTheirHealthInfor.pdf", "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_PHCDRR_2", "title": "Syndromic Surveillance Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": "https://qpp.cms.gov/docs/pi_specifications/Measure%20Specifications/2019MIPSPIMeasuresSyndromicSurveillanceReporting.pdf", "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_PHCDRR_2_MULTI", "title": "Syndromic Surveillance Reporting for Multiple Registry Engagement", "description": "Report as true if, active engagement with more than one Syndromic Surveillance registry in accordance with PI_PHCDRR_2.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": 10, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_PHCDRR_2_EX_1", "title": "Syndromic Surveillance Reporting Exclusion", "description": "Any MIPS eligible clinician who is not in a category of health care providers from which ambulatory syndromic surveillance data is collected by their jurisdiction's syndromic surveillance system.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "weight": 0, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_PHCDRR_2_EX_2", "title": "Syndromic Surveillance Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data in the specific standards required to meet the CEHRT definition at the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "weight": 0, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_PHCDRR_2_EX_3", "title": "Syndromic Surveillance Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction where no public health agency has declared readiness to receive syndromic surveillance data from MIPS eligible clinicians as of 6 months prior to the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "weight": 0, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": "https://qpp.cms.gov/docs/pi_specifications/Measure%20Specifications/2019MIPSPIMeasuresImmunizationRegistryReporting.pdf", "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_PHCDRR_1_MULTI", "title": "Immunization 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"nationalQualityStrategyDomain": null, "measureType": "patientEngagementExperience", "measureId": "CAHPS_11", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [], "isHighPriority": true, "isIcdImpacted": false, "primarySteward": "Agency for Healthcare Research & Quality", "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ], "isRegistryMeasure": false }, { "category": "quality", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "metricType": "cahps", "title": "CAHPS for ACO SSM: Stewardship of Patient Resources", "description": "", "nationalQualityStrategyDomain": null, "measureType": "patientEngagementExperience", "measureId": "CAHPS_ACO_34", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [], "isHighPriority": true, "isIcdImpacted": false, "primarySteward": "Agency for Healthcare Research & Quality", "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ], "isRegistryMeasure": false }, { "category": "ia", "title": "Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record", "description": "- Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent and emergent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:- Expanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);- Use of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); 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participation in the Quality Payment Program website testing is an activity for eligible clinicians who have worked with CMS to provided substantive, timely, and responsive input to improve the CMS Quality Payment Program website through product user-testing that enhances system and program accessibility, readability and responsiveness as well as providing feedback for developing tools and guidance thereby allowing for a more user-friendly and accessible clinician and practice Quality Payment Program website experience.", "measureId": "IA_EPA_5", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "expandedPracticeAccess" }, { "category": "ia", "title": "Participation in Systematic Anticoagulation Program", "description": "Participation in a systematic anticoagulation program (coagulation clinic, patient self-reporting program, or patient self-management program) for 60 percent of practice patients in the transition year and 75 percent of practice patients in Quality Payment Program Year 2 and future years, who receive anti-coagulation medications (warfarin or other coagulation cascade inhibitors).", "measureId": "IA_PM_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "populationManagement" }, { "category": "ia", "title": "Anticoagulant Management Improvements", "description": "Individual MIPS eligible clinicians and groups who prescribe oral Vitamin K antagonist therapy (warfarin) must attest that, for 60 percent of practice patients in the transition year and 75 percent of practice patients in Quality Payment Program Year 2 and future years, their ambulatory care patients receiving warfarin are being managed by one or more of the following improvement activities: - Patients are being managed by an anticoagulant management service, that involves systematic and coordinated care, incorporating comprehensive patient education, systematic prothrombin time (PT-INR) testing, tracking, follow-up, and patient communication of results and dosing decisions;- Patients are being managed according to validated electronic decision support and clinical management tools that involve systematic and coordinated care, incorporating comprehensive patient education, systematic PT-INR testing, tracking, follow-up, and patient communication of results and dosing decisions;- For rural or remote patients, patients are managed using remote monitoring or telehealth options that involve systematic and coordinated care, incorporating comprehensive patient education, systematic PT-INR testing, tracking, follow-up, and patient communication of results and dosing decisions; and/or- For patients who demonstrate motivation, competency, and adherence, patients are managed using either a patient self-testing (PST) or patient-self-management (PSM) program.", "measureId": "IA_PM_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "populationManagement" }, { "category": "ia", "title": "RHC, IHS or FQHC quality improvement activities", "description": "Participating in a Rural Health Clinic (RHC), Indian Health Service medium Management (IHS), or Federally Qualified Health Center in ongoing engagement activities that contribute to more formal quality reporting , and that include receiving quality data back for broader quality improvement and benchmarking improvement which will ultimately benefit patients. Participation in Indian Health Service, as an improvement activity, requires MIPS eligible clinicians and groups to deliver care to federally recognized American Indian and Alaska Native populations in the U.S. and in the course of that care implement continuous clinical practice improvement including reporting data on quality of services being provided and receiving feedback to make improvements over time.", "measureId": "IA_PM_3", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "populationManagement" }, { "category": "ia", "title": "Glycemic management services", "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: For the first performance year, at least 60 percent of medical records with documentation of an individualized glycemic treatment goal that: a) Takes into account patient-specific factors, including, at least 1) age, 2) comorbidities, and 3) risk for hypoglycemia, andb) Is reassessed at least annually.The performance threshold will increase to 75 percent for the second performance year and onward.Clinician would attest that, 60 percent for first year, or 75 percent for the second year, of their medical records that document individualized glycemic treatment represent patients who are being treated for at least 90 days during the performance period.", "measureId": "IA_PM_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "populationManagement" }, { "category": "ia", "title": "Engagement of community for health status improvement", "description": "Take steps to improve health status of communities, such as collaborating with key partners and stakeholders to implement evidenced-based practices to improve a specific chronic condition. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist MIPS eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.", "measureId": "IA_PM_5", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement" }, { "category": "ia", "title": "Use of toolsets or other resources to close healthcare disparities across communities", "description": "Take steps to improve healthcare disparities, such as Population Health Toolkit or other resources identified by CMS, the Learning and Action Network, Quality Innovation Network, or National Coordinating Center. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.", "measureId": "IA_PM_6", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement" }, { "category": "ia", "title": "Use of QCDR for feedback reports that incorporate population health", "description": "Use of a QCDR to generate regular feedback reports that summarize local practice patterns and treatment outcomes, including for vulnerable populations.", "measureId": "IA_PM_7", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "populationManagement" }, { "category": "ia", "title": "Use of QCDR data for quality improvement such as comparative analysis reports across patient populations", "description": "Participation in a QCDR, clinical data registries, or other registries run by other government agencies such as FDA, or private entities such as a hospital or medical or surgical society. Activity must include use of QCDR data for quality improvement (e.g., comparative analysis across specific patient populations for adverse outcomes after an outpatient surgical procedure and corrective steps to address adverse outcome).", "measureId": "IA_PM_10", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement" }, { "category": "ia", "title": "Regular Review Practices in Place on Targeted Patient Population Needs", "description": "Implementation of regular reviews of targeted patient population needs, such as structured clinical case reviews, which includes access to reports that show unique characteristics of eligible clinician's patient population, identification of vulnerable patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources.", "measureId": "IA_PM_11", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement" }, { "category": "ia", "title": "Population empanelment", "description": "Empanel (assign responsibility for) the total population, linking each patient to a MIPS eligible clinician or group or care team.Empanelment 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. Empanelment identifies the patients and population for whom the MIPS eligible clinician or group and/or care team is responsible and is the foundation for the relationship continuity between patient and MIPS eligible clinician or group /care team that is at the heart of comprehensive primary care. Effective empanelment requires identification of the \"active population\" of the practice: those patients who identify and use your practice as a source for primary care. There are many ways to define \"active patients\" operationally, but generally, the definition of \"active patients\" includes patients who have sought care within the last 24 to 36 months, allowing inclusion of younger patients who have minimal acute or preventive health care.", "measureId": "IA_PM_12", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement" }, { "category": "ia", "title": "Chronic Care and Preventative Care Management for Empaneled Patients", "description": "In order to receive credit for this activity, a MIPS eligible clinician must manage chronic and preventive care for empaneled patients (that is, patients assigned to care teams for the purpose of population health management), which could include one or more of the following actions:-   Provide patients annually with an opportunity for development and/or adjustment of an individualized plan of care as appropriate to age and health status, including health risk appraisal; gender, age and condition-specific preventive care services; and plan of care for chronic conditions;-   Use evidence based, condition-specific pathways for care of chronic conditions (for example, hypertension, diabetes, depression, asthma, and heart failure). These might include, but are not limited to, the NCQA Diabetes Recognition Program (DRP)93 and the NCQA Heart/Stroke Recognition Program (HSRP)94;-   Use pre-visit planning, that is, preparations for conversations or actions to propose with patient before an in-office visit to optimize preventive care and team management of patients with chronic conditions;-   Use panel support tools, (that is, registry functionality) or other technology that can use clinical data to identify trends or data points in patient records to identify services due;-   Use predictive analytical models to predict risk, onset and progression of chronic diseases; and/orUse reminders and outreach (e.g., phone calls, emails, postcards, patient portals, and community health workers where available) to alert and educate patients about services due; and/or routine medication reconciliation.", "measureId": "IA_PM_13", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement" }, { "category": "ia", "title": "Implementation of methodologies for improvements in longitudinal care management for high risk patients", "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: Use 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; Use a personalized plan of care for patients at high risk for adverse health outcome or harm, integrating patient goals, values and priorities; and/orUse on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients.", "measureId": "IA_PM_14", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement" }, { "category": "ia", "title": "Implementation of episodic care management practice improvements", "description": "Provide episodic care management, including management across transitions and referrals that could include one or more of the following:Routine 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/orManaging care intensively through new diagnoses, injuries and exacerbations of illness.", "measureId": "IA_PM_15", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement" }, { "category": "ia", "title": "Implementation of medication management practice improvements", "description": "Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; Integrate a pharmacist into the care team; and/orConduct periodic, structured medication reviews.", "measureId": "IA_PM_16", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement" }, { "category": "ia", "title": "Participation in Population Health Research", "description": "Participation in federally and/or privately funded research that identifies interventions, tools, or processes that can improve a targeted patient population.", "measureId": "IA_PM_17", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement" }, { "category": "ia", "title": "Provide Clinical-Community Linkages", "description": "Engaging community health workers to provide a comprehensive link to community resources through family-based services focusing on success in health, education, and self-sufficiency. This activity supports individual MIPS eligible clinicians or groups that coordinate with primary care and other clinicians, engage and support patients, use of health information technology, and employ quality measurement and improvement processes. An example of this community based program is the NCQA Patient-Centered Connected Care (PCCC) Recognition Program or other such programs that meet these criteria.", "measureId": "IA_PM_18", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement" }, { "category": "ia", "title": "Glycemic Screening Services", "description": "For at-risk outpatient Medicare beneficiaries, individual MIPS eligible clinicians and groups must attest to implementation of systematic preventive approaches in clinical practice for at least 60 percent for the 2018 performance period and 75 percent in future years, of electronic medical records with documentation of screening patients for abnormal blood glucose according to current US Preventive Services Task Force (USPSTF) and/or American Diabetes Association (ADA) guidelines.", "measureId": "IA_PM_19", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement" }, { "category": "ia", "title": "Glycemic Referring Services", "description": "For at-risk outpatient Medicare beneficiaries, individual MIPS eligible clinicians and groups must attest to implementation of systematic preventive approaches in clinical practice for at least 60 percent for the CY 2018 performance period and 75 percent in future years, of medical records with documentation of referring eligible patients with prediabetes to a CDC-recognized diabetes prevention program operating under the framework of the National Diabetes Prevention Program.", "measureId": "IA_PM_20", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement" }, { "category": "ia", "title": "Advance Care Planning", "description": "Implementation of practices/processes to develop advance care planning that includes: documenting the advance care plan or living will within the medical record, educating clinicians about advance care planning motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement, educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation, as well as informing clinicians of the healthcare policy side of advance care planning.", "measureId": "IA_PM_21", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement" }, { "category": "ia", "title": "Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop", "description": "Performance of regular practices that include providing specialist reports back to the referring individual MIPS eligible clinician or group to close the referral loop or where the referring individual MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the EHR technology.", "measureId": "IA_CC_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "title": "Implementation of improvements that contribute to more timely communication of test results", "description": "Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.", "measureId": "IA_CC_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "title": "Implementation of additional activity as a result of TA for improving care coordination", "description": "Implementation of at least one additional recommended activity from the Quality Innovation Network-Quality Improvement Organization after technical assistance has been provided related to improving care coordination.", "measureId": "IA_CC_3", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "title": "TCPI Participation", "description": "Participation in the CMS Transforming Clinical Practice Initiative", "measureId": "IA_CC_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "title": "CMS partner in Patients Hospital Engagement Network", "description": "Membership and participation in a CMS Partnership for Patients Hospital Engagement Network.", "measureId": "IA_CC_5", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "title": "Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination", "description": "Participation in a Qualified Clinical Data Registry, demonstrating performance of activities that promote use of standard practices, tools and processes for quality improvement (e.g., documented preventative screening and vaccinations that can be shared across MIPS eligible clinician or groups).", "measureId": "IA_CC_6", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "title": "Regular training in care coordination", "description": "Implementation of regular care coordination training.", "measureId": "IA_CC_7", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "title": "Implementation of documentation improvements for practice/process improvements", "description": "Implementation of practices/processes that document care coordination activities (e.g., a documented care coordination encounter that tracks all clinical staff involved and communications from date patient is scheduled for outpatient procedure through day of procedure).", "measureId": "IA_CC_8", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "title": "Implementation of practices/processes for developing regular individual care plans", "description": "Implementation of practices/processes, including a discussion on care, to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s). Individual care plans should include consideration of a patient's goals and priorities, as well as desired outcomes of care.", "measureId": "IA_CC_9", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "title": "Care transition documentation practice improvements", "description": "In order to receive credit for this activity, a MIPS eligible clinician must document practices/processes for care transition with documentation of how a MIPS eligible clinician or group carried out an action plan for the patient with the patient's preferences in mind (that is, a \"patient-centered\" plan) during the first 30 days following a discharge. Examples of these practices/processes for care transition include: staff involved in the care transition; phone calls conducted in support of transition; accompaniments of patients to appointments or other navigation actions; home visits; patient information access to their medical records; real time communication between PCP and consulting clinicians; PCP included on specialist follow-up or transition communications.", "measureId": "IA_CC_10", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "title": "Care transition standard operational improvements", "description": "Establish standard operations to manage transitions of care that could include one or more of the following: Establish 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/orPartner with community or hospital-based transitional care services.", "measureId": "IA_CC_11", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "title": "Care coordination agreements that promote improvements in patient tracking across settings", "description": "Establish effective care coordination and active referral management that could include one or more of the following:Establish 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; Track patients referred to specialist through the entire process; and/orSystematically integrate information from referrals into the plan of care.", "measureId": "IA_CC_12", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "title": "Practice Improvements for Bilateral Exchange of Patient Information", "description": "Ensure that there is bilateral exchange of necessary patient information to guide patient care, such as Open Notes, that could include one or more of the following: - Participate in a Health Information Exchange if available; and/or - Use structured referral notes.", "measureId": "IA_CC_13", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "title": "Practice Improvements that Engage Community Resources to Support Patient Health Goals", "description": "Develop pathways to neighborhood/community-based resources to support patient health goals that could include one or more of the following: - Maintain formal (referral) links to community-based chronic disease self-management support programs, exercise programs and other wellness resources with the potential for bidirectional flow of information; and provide a guide to available community resources.- Including through the use of tools that facilitate electronic communication between settings;- Screen patients for health-harming legal needs;- Screen and assess patients for social needs using tools that are preferably health IT enabled and that include to any extent standards-based, coded question/field for the capture of data as is feasible and available as part of such tool; and/or- Provide a guide to available community resources.", "measureId": "IA_CC_14", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "title": "PSH Care Coordination", "description": "Participation in a Perioperative Surgical Home (PSH) that provides a patient-centered, physician-led, interdisciplinary, and team-based system of coordinated patient care, which coordinates care from pre-procedure assessment through the acute care episode, recovery, and post-acute care. This activity allows for reporting of strategies and processes related to care coordination of patients receiving surgical or procedural care within a PSH. The clinician must perform one or more of the following care coordination activities:- Coordinate with care managers/navigators in preoperative clinic to plan and implementation comprehensive post discharge plan of care;- Deploy perioperative clinic and care processes to reduce post-operative visits to emergency rooms;- Implement evidence-informed practices and standardize care across the entire spectrum of surgical patients; or- Implement processes to ensure effective communications and education of patients' post-discharge instructions.", "measureId": "IA_CC_15", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "title": "Primary Care Physician and Behavioral Health Bilateral Electronic Exchange of Information for Shared Patients", "description": "The primary care and behavioral health practices use the same electronic health record system for shared patients or have an established bidirectional flow of primary care and behavioral health records.", "measureId": "IA_CC_16", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "title": "Patient Navigator Program", "description": "Implement a Patient Navigator Program that offers evidence-based resources and tools to reduce avoidable hospital readmissions, utilizing a patient-centered and team-based approach, leveraging evidence-based best practices to improve care for patients by making hospitalizations less stressful, and the recovery period more supportive by implementing quality improvement strategies.", "measureId": "IA_CC_17", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "careCoordination" }, { "category": "ia", "title": "Relationship-Centered Communication", "description": "In order to receive credit for this activity, MIPS eligible clinicians must participate in a minimum of eight hours of training on relationship-centered care80 tenets such as making effective open-ended inquiries; eliciting patient stories and perspectives; listening and responding with empathy; using the ART (ask, respond, tell) communication technique to engage patients, and developing a shared care plan. The training may be conducted in formats such as, but not limited to: interactive simulations practicing the skills above, or didactic instructions on how to implement improvement action plans, monitor progress, and promote stability around improved clinician communication.", "measureId": "IA_CC_18", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "title": "Use of certified EHR to capture patient reported outcomes", "description": "In support of improving patient access, performing additional activities that enable capture of patient reported outcomes (e.g., home blood pressure, blood glucose logs, food diaries, at-risk health factors such as tobacco or alcohol use, etc.) or patient activation measures through use of certified EHR technology, containing this data in a separate queue for clinician recognition and review.", "measureId": "IA_BE_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "title": "Use of QCDR to support clinical decision making", "description": "Participation in a QCDR, demonstrating performance of activities that promote implementation of shared clinical decision making capabilities.", "measureId": "IA_BE_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "title": "Engagement with QIN-QIO to implement self-management training programs", "description": "Engagement with a Quality Innovation Network-Quality Improvement Organization, which may include participation in self-management training programs such as diabetes.", "measureId": "IA_BE_3", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "title": "Engagement of patients through implementation of improvements in patient portal", "description": "Access to an enhanced patient portal that provides up to date information related to relevant chronic disease health or blood pressure control, and includes interactive features allowing patients to enter health information and/or enables bidirectional communication about medication changes and adherence.", "measureId": "IA_BE_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "title": "Enhancements/regular updates to practice websites/tools that also include considerations for patients with cognitive disabilities", "description": "Enhancements and ongoing regular updates and use of websites/tools that include consideration for compliance with section 508 of the Rehabilitation Act of 1973 or for improved design for patients with cognitive disabilities. Refer to the CMS website on Section 508 of the Rehabilitation Act https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/Section508/index.html?redirect=/InfoTechGenInfo/07_Section508.asp that requires that institutions receiving federal funds solicit, procure, maintain and use all electronic and information technology (EIT) so that equal or alternate/comparable access is given to members of the public with and without disabilities. For example, this includes designing a patient portal or website that is compliant with section 508 of the Rehabilitation Act of 1973", "measureId": "IA_BE_5", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "title": "Collection and follow-up on patient experience and satisfaction data on beneficiary engagement", "description": "Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of improvement plan.", "measureId": "IA_BE_6", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "title": "Participation in a QCDR, that promotes use of patient engagement tools.", "description": "Participation in a QCDR, that promotes use of patient engagement tools.", "measureId": "IA_BE_7", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "title": "Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive.", "description": "Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive.", "measureId": "IA_BE_8", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "title": "Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement.", "description": "Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement.", "measureId": "IA_BE_9", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "title": "Participation in a QCDR, that promotes implementation of patient self-action plans.", "description": "Participation in a QCDR, that promotes implementation of patient self-action plans.", "measureId": "IA_BE_10", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "title": "Participation in a QCDR, that promotes use of processes and tools that engage patients for adherence to treatment plan.", "description": "Participation in a QCDR, that promotes use of processes and tools that engage patients for adherence to treatment plan.", "measureId": "IA_BE_11", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "title": "Use evidence-based decision aids to support shared decision-making.", "description": "Use evidence-based decision aids to support shared decision-making.", "measureId": "IA_BE_12", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "title": "Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.", "description": "Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.", "measureId": "IA_BE_13", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "title": "Engage Patients and Families to Guide Improvement in the System of Care", "description": "Engage patients and families to guide improvement in the system of care by leveraging digital tools for ongoing guidance and assessments outside the encounter, including the collection and use of patient data for return-to-work and patient quality of life improvement. Platforms and devices that collect patient-generated health data (PGHD) must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient, including patient reported outcomes (PROs). Examples include patient engagement and outcomes tracking platforms, cellular or web-enabled bi-directional systems, and other devices that transmit clinically valid objective and subjective data back to care teams. Because many consumer-grade devices capture PGHD (for example, wellness devices), platforms or devices eligible for this improvement activity must be, at a minimum, endorsed and offered clinically by care teams to patients to automatically send ongoing guidance (one way). Platforms and devices that additionally collect PGHD must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient (e.g. automated patient-facing instructions based on glucometer readings). Therefore, unlike passive platforms or devices that may collect but do not transmit PGHD in real or near-real time to clinical care teams, active devices and platforms can inform the patient or the clinical care team in a timely manner of important parameters regarding a patient's status, adherence, comprehension, and indicators of clinical concern.", "measureId": "IA_BE_14", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "title": "Engagement of Patients, Family, and Caregivers in Developing a Plan of Care", "description": "Engage patients, family, and caregivers in developing a plan of care and prioritizing their goals for action, documented in the electronic health record (EHR) technology.", "measureId": "IA_BE_15", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "title": "Evidenced-based techniques to promote self-management into usual care", "description": "Incorporate evidence-based techniques to promote self-management into usual care, using techniques such as goal setting with structured follow-up, Teach Back, action planning or motivational interviewing.", "measureId": "IA_BE_16", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "title": "Use of tools to assist patient self-management", "description": "Use tools to assist patients in assessing their need for support for self-management (e.g., the Patient Activation Measure or How's My Health).", "measureId": "IA_BE_17", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "title": "Provide peer-led support for self-management.", "description": "Provide peer-led support for self-management.", "measureId": "IA_BE_18", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "title": "Use group visits for common chronic conditions (e.g., diabetes).", "description": "Use group visits for common chronic conditions (e.g., diabetes).", "measureId": "IA_BE_19", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "title": "Implementation of condition-specific chronic disease self-management support programs", "description": "Provide condition-specific chronic disease self-management support programs or coaching or link patients to those programs in the community.", "measureId": "IA_BE_20", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "title": "Improved Practices that Disseminate Appropriate Self-Management Materials", "description": "Provide self-management materials at an appropriate literacy level and in an appropriate language.", "measureId": "IA_BE_21", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "title": "Improved Practices that Engage Patients Pre-Visit", "description": "Implementation of workflow changes that engage patients prior to the visit, such as a pre-visit development of a shared visit agenda with the patient, or targeted pre-visit laboratory testing that will be resulted and available to the MIPS eligible clinician to review and discuss during the patient's appointment..", "measureId": "IA_BE_22", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "title": "Integration of patient coaching practices between visits", "description": "Provide coaching between visits with follow-up on care plan and goals.", "measureId": "IA_BE_23", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "title": "Financial Navigation Program", "description": "In order to receive credit for this activity, MIPS eligible clinicians must attest that their practice provides financial counseling to patients or their caregiver about costs of care and an exploration of different payment options. The MIPS eligible clinician may accomplish this by working with other members of their practice (for example, financial counselor or patient navigator) as part of a team-based care approach in which members of the patient care team collaborate to support patient- centered goals. For example, a financial counselor could provide patients with resources with further information or support options, or facilitate a conversation with a patient or caregiver that could address concerns. This activity may occur during diagnosis stage, before treatment, during treatment, and/or during survivorship planning, as appropriate.", "measureId": "IA_BE_24", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "title": "Participation in an AHRQ-listed patient safety organization.", "description": "Participation in an AHRQ-listed patient safety organization.", "measureId": "IA_PSPA_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Participation in MOC Part IV", "description": "In order to receive credit for this activity, a MIPS eligible clinician must participate in Maintenance of Certification (MOC) Part IV97. Maintenance of Certification (MOC) Part IV requires clinicians to perform monthly activities across practice to regularly assess performance by reviewing outcomes addressing identified areas for improvement and evaluating the results. Some examples of activities that can be completed to receive MOC Part IV credit are: the American Board of Internal Medicine (ABIM) Approved Quality Improvement (AQI) Program,98 National Cardiovascular Data Registry (NCDR) Clinical Quality Coach,99 Quality Practice Initiative Certification Program,100 American Board of Medical Specialties Practice Performance Improvement Module101 or American Society of Anesthesiologists (ASA) Simulation Education Network,102 for improving professional practice including participation in a local, regional or national outcomes registry or quality assessment program; specialty- specific activities including Safety Certification in Outpatient Practice Excellence (SCOPE);103 American Psychiatric Association (APA) Performance in Practice modules.104", "measureId": "IA_PSPA_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS® or Other Similar Activity", "description": "For MIPS eligible clinicians not participating in Maintenance of Certification (MOC) Part IV, new engagement for MOC Part IV, such as the Institute for Healthcare Improvement (IHI) Training/Forum Event; National Academy of Medicine, Agency for Healthcare Research and Quality (AHRQ) Team STEPPS, or the American Board of Family Medicine (ABFM) Performance in Practice Modules.", "measureId": "IA_PSPA_3", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Administration of the AHRQ Survey of Patient Safety Culture", "description": "Administration of the AHRQ Survey of Patient Safety Culture and submission of data to the comparative database (refer to AHRQ Survey of Patient Safety Culture website http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html).Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.", "measureId": "IA_PSPA_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Annual registration in the Prescription Drug Monitoring Program", "description": "Annual registration by eligible clinician or group in the prescription drug monitoring program of the state where they practice. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and groups must participate for a minimum of 6 months.", "measureId": "IA_PSPA_5", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Consultation of the Prescription Drug Monitoring Program", "description": "Clinicians would attest to reviewing the patients' history of controlled substance prescription using state prescription drug monitoring program (PDMP) data prior to the issuance of a Controlled Substance Schedule II (CSII) opioid prescription lasting longer than 3 days. For the transition year, clinicians would attest to 60 percent review of applicable patient's history. For the Quality Payment Program Year 2 and future years, clinicians would attest to 75 percent review of applicable patient's history performance.", "measureId": "IA_PSPA_6", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Use of QCDR data for ongoing practice assessment and improvements", "description": "Use of QCDR data, for ongoing practice assessment and improvements in patient safety.", "measureId": "IA_PSPA_7", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Use of Patient Safety Tools", "description": "In order to receive credit for this activity, a MIPS eligible clinician must use tools that assist specialty practices in tracking specific measures that are meaningful to their practice.Some examples of tools that could satisfy this activity are: a surgical risk calculator; evidence based protocols, such as Enhanced Recovery After Surgery (ERAS) protocols;106 the Centers for Disease Control (CDC) Guide for Infection Prevention for Outpatient Settings107 predictive algorithms; and the opiate risk tool (ORT)108 or similar tool.", "measureId": "IA_PSPA_8", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Completion of the AMA STEPS Forward program", "description": "Completion of the American Medical Association's STEPS Forward program.", "measureId": "IA_PSPA_9", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Completion of training and receipt of approved waiver for provision opioid medication-assisted treatments", "description": "Completion of training and obtaining an approved waiver for provision of medication -assisted treatment of opioid use disorders using buprenorphine.", "measureId": "IA_PSPA_10", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Participation in CAHPS or other supplemental questionnaire", "description": "Participation in the Consumer Assessment of Healthcare Providers and Systems Survey or other supplemental questionnaire items (e.g., Cultural Competence or Health Information Technology supplemental item sets).", "measureId": "IA_PSPA_11", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Participation in private payer CPIA", "description": "Participation in designated private payer clinical practice improvement activities.", "measureId": "IA_PSPA_12", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Participation in Joint Commission Evaluation Initiative", "description": "Participation in Joint Commission Ongoing Professional Practice Evaluation initiative", "measureId": "IA_PSPA_13", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Participation in Quality Improvement Initiatives", "description": "Participation in other quality improvement programs such as Bridges to Excellence or American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.", "measureId": "IA_PSPA_14", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Implementation of an ASP", "description": "Change Activity Description to: Leadership of an Antimicrobial Stewardship Program (ASP) that includes implementation of an ASP that measures the appropriate use of antibiotics for several different conditions (such as but not limited to upper respiratory infection treatment in children, diagnosis of pharyngitis, bronchitis treatment in adults) according to clinical guidelines for diagnostics and therapeutics. Specific activities may include: - Develop facility-specific antibiogram and prepare report of findings with specific action plan that aligns with overall facility or practice strategic plan.- Lead the development, implementation, and monitoring of patient care and patient safety protocols for the delivery of ASP including protocols pertaining to the most appropriate setting for such services (i.e., outpatient or inpatient). - Assist in improving ASP service line efficiency and effectiveness by evaluating and recommending improvements in the management structure and workflow of ASP processes.- Manage compliance of the ASP policies and assist with implementation of corrective actions in accordance with facility or clinic compliance policies and hospital medical staff by-laws. - Lead the education and training of professional support staff for the purpose of maintaining an efficient and effective ASP.- Coordinate communications between ASP management and facility or practice personnel regarding activities, services, and operational/clinical protocols to achieve overall compliance and understanding of the ASP.- Assist, at the request of the facility or practice, in preparing for and responding to third-party requests, including but not limited to payer audits, governmental inquiries, and professional inquiries that pertain to the ASP service line. - Implementing and tracking an evidence-based policy or practice aimed at improving antibiotic prescribing practices for high-priority conditions. - Developing and implementing evidence-based protocols and decision-support for diagnosis and treatment of common infections.- Implementing evidence-based protocols that align with recommendations in the Centers for Disease Control and Prevention's Core Elements of Outpatient Antibiotic Stewardship guidance", "measureId": "IA_PSPA_15", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Use of decision support and standardized treatment protocols", "description": "Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs.", "measureId": "IA_PSPA_16", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Implementation of analytic capabilities to manage total cost of care for practice population", "description": "In order to receive credit for this activity, a MIPS eligible clinician must conduct or build the capacity to conduct analytic activities to manage total cost of care for the practice population. Examples of these activities could include:1.) Train appropriate staff on interpretation of cost and utilization information;2.) Use available data regularly to analyze opportunities to reduce cost through improved care. An example of a platform with the necessary analytic capability to do this is the American Society for Gastrointestinal (GI) Endoscopy's GI Operations Benchmarking Platform.", "measureId": "IA_PSPA_17", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Measurement and Improvement at the Practice and Panel Level", "description": "Measure and improve quality at the practice and panel level, such as the American Board of Orthopaedic Surgery (ABOS) Physician Scorecards, that could include one or more of the following:- Regularly review measures of quality, utilization, patient satisfaction and other measures that may be useful at the practice level and at the level of the care team or MIPS eligible clinician or group (panel); and/or - Use relevant data sources to create benchmarks and goals for performance at the practice level and panel level.", "measureId": "IA_PSPA_18", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Implementation of formal quality improvement methods, practice changes, or other practice improvement processes", "description": "Adopt a formal model for quality improvement and create a culture in which all staff actively participates in improvement activities that could include one or more of the following such as: - Multi-Source Feedback; - Train all staff in quality improvement methods; - Integrate practice change/quality improvement into staff duties; - Engage all staff in identifying and testing practices changes; - Designate regular team meetings to review data and plan improvement cycles; - Promote transparency and accelerate improvement by sharing practice level and panel level quality of care, patient experience and utilization data with staff; and/or - Promote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data.", "measureId": "IA_PSPA_19", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes", "description": "Ensure full engagement of clinical and administrative leadership in practice improvement that could include one or more of the following: Make responsibility for guidance of practice change a component of clinical and administrative leadership roles; Allocate time for clinical and administrative leadership for practice improvement efforts, including participation in regular team meetings; and/orIncorporate population health, quality and patient experience metrics in regular reviews of practice performance.", "measureId": "IA_PSPA_20", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Implementation of fall screening and assessment programs", "description": "Implementation of fall screening and assessment programs to identify patients at risk for falls and address modifiable risk factors (e.g., Clinical decision support/prompts in the electronic health record that help manage the use of medications, such as benzodiazepines, that increase fall risk).", "measureId": "IA_PSPA_21", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "CDC Training on CDC's Guideline for Prescribing Opioids for Chronic Pain", "description": "Completion of all the modules of the Centers for Disease Control and Prevention (CDC) course \"Applying CDC's Guideline for Prescribing Opioids\" that reviews the 2016 \"Guideline for Prescribing Opioids for Chronic Pain.\" Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.", "measureId": "IA_PSPA_22", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Completion of CDC Training on Antibiotic Stewardship", "description": "Completion of all modules of the Centers for Disease Control and Prevention antibiotic stewardship course. Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.", "measureId": "IA_PSPA_23", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Initiate CDC Training on Antibiotic Stewardship", "description": "Completion of greater than 50 percent of the modules of the Centers for Disease Control and Prevention antibiotic stewardship course. Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis, but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.", "measureId": "IA_PSPA_24", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Cost Display for Laboratory and Radiographic Orders", "description": "Implementation of a cost display for laboratory and radiographic orders, such as costs that can be obtained through the Medicare clinical laboratory fee schedule.", "measureId": "IA_PSPA_25", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Communication of Unscheduled Visit for Adverse Drug Event and Nature of Event", "description": "A MIPS eligible clinician providing unscheduled care (such as an emergency room, urgent care, or other unplanned encounter) attests that, for greater than 75 percent of case visits that result from a clinically significant adverse drug event, the MIPS eligible clinician provides information, including through the use of health IT to the patient's primary care clinician regarding both the unscheduled visit and the nature of the adverse drug event within 48 hours. A clinically significant adverse event is defined as a medication-related harm or injury such as side-effects, supratherapeutic effects, allergic reactions, laboratory abnormalities, or medication errors requiring urgent/emergent evaluation, treatment, or hospitalization.", "measureId": "IA_PSPA_26", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Invasive Procedure or Surgery Anticoagulation Medication Management", "description": "For an anticoagulated patient undergoing a planned invasive procedure for which interruption in anticoagulation is anticipated, including patients taking vitamin K antagonists (warfarin), target specific oral anticoagulants (such as apixaban, dabigatran, and rivaroxaban), and heparins/low molecular weight heparins, documentation, including through the use of electronic tools, that the plan for anticoagulation management in the periprocedural period was discussed with the patient and with the clinician responsible for managing the patient's anticoagulation. Elements of the plan should include the following: discontinuation, resumption, and, if applicable, bridging, laboratory monitoring, and management of concomitant antithrombotic medications (such as antiplatelets and nonsteroidal anti-inflammatory drugs (NSAIDs)). An invasive or surgical procedure is defined as a procedure in which skin or mucous membranes and connective tissue are incised, or an instrument is introduced through a natural body orifice.", "measureId": "IA_PSPA_27", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Completion of an Accredited Safety or Quality Improvement Program", "description": "Completion of an accredited performance improvement continuing medical education program that addresses performance or quality improvement according to the following criteria:- The activity must address a quality or safety gap that is supported by a needs assessment or problem analysis, or must support the completion of such a needs assessment as part of the activity;- The activity must have specific, measurable aim(s) for improvement;- The activity must include interventions intended to result in improvement;- The activity must include data collection and analysis of performance data to assess the impact of the interventions; andThe accredited program must define meaningful clinician participation in their activity, describe the mechanism for identifying clinicians who meet the requirements, and provide participant completion information.", "measureId": "IA_PSPA_28", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Consulting AUC Using Clinical Decision Support when Ordering Advanced", "description": "Clinicians attest that they are consulting specified applicable AUC through a qualified clinical decision support mechanism for all applicable imaging services furnished in an applicable setting, paid for under an applicable payment system, and ordered on or after January 1, 2018. This activity is for clinicians that are early adopters of the Medicare AUC program (2018 performance year) and for clinicians that begin the Medicare AUC program in future years as specified in our regulation at §414.94. The AUC program is required under section 218 of the Protecting Access to Medicare Act of 2014. Qualified mechanisms will be able to provide a report to the ordering clinician that can be used to assess patterns of image-ordering and improve upon those patterns to ensure that patients are receiving the most appropriate imaging for their individual condition.", "measureId": "IA_PSPA_29", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "PCI Bleeding Campaign", "description": "Participation in the PCI Bleeding Campaign which is a national quality improvement program that provides infrastructure for a learning network and offers evidence-based resources and tools to reduce avoidable bleeding associated with patients who receive a percutaneous coronary intervention (PCI).The program uses a patient-centered and team-based approach, leveraging evidence-based best practices to improve care for PCI patients by implementing quality improvement strategies:- Radial-artery access,- Bivalirudin, and- Use of vascular closure devices.", "measureId": "IA_PSPA_30", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Patient Medication Risk Education", "description": "In order to receive credit for this activity, MIPS eligible clinicians must provide both written and verbal education regarding the risks of concurrent opioid and benzodiazepine use for patients who are prescribed both benzodiazepines and opioids. Education must be completed for at least 75% of qualifying patients and occur: (1) at the time of initial co-prescribing and again following greater than 6 months of co- prescribing of benzodiazepines and opioids, or (2) at least once per MIPS performance period for patients taking concurrent opioid and benzodiazepine therapy.", "measureId": "IA_PSPA_31", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Use of CDC Guideline for Clinical Decision Support to Prescribe Opioids for Chronic Pain via Clinical Decision Support", "description": "In order to receive credit for this activity, MIPS eligible clinicians must utilize the Centers for Disease Control (CDC) Guideline for Prescribing Opioids for Chronic Pain[1] via clinical decision support (CDS). For CDS to be most effective, it needs to be built directly into the clinician workflow and support decision making on a specific patient at the point of care. Specific examples of how the guideline could be incorporated into a CDS workflow include, but are not limited to: electronic health record (EHR)-based prescribing prompts, order sets that require review of guidelines before prescriptions can be entered, and prompts requiring review of guidelines before a subsequent action can be taken in the record.", "measureId": "IA_PSPA_32", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "title": "Engagement of New Medicaid Patients and Follow-up", "description": "Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare. A timely manner is defined as within 10 business days for this activity.", "measureId": "IA_AHE_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "achievingHealthEquity" }, { "category": "ia", "title": "Leveraging a QCDR to standardize processes for screening", "description": "Participation in a QCDR, demonstrating performance of activities for use of standardized processes for screening for social determinants of health such as food security, employment and housing. Use of supporting tools that can be incorporated into the certified EHR technology is also suggested.", "measureId": "IA_AHE_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "achievingHealthEquity" }, { "category": "ia", "title": "Promote Use of Patient-Reported Outcome Tools", "description": "Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PQH-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.", "measureId": "IA_AHE_3", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "achievingHealthEquity" }, { "category": "ia", "title": "Leveraging a QCDR for use of standard questionnaires", "description": "Participation in a QCDR, demonstrating performance of activities for use of standard questionnaires for assessing improvements in health disparities related to functional health status (e.g., use of Seattle Angina Questionnaire, MD Anderson Symptom Inventory, and/or SF-12/VR-12 functional health status assessment).", "measureId": "IA_AHE_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "achievingHealthEquity" }, { "category": "ia", "title": "MIPS Eligible Clinician Leadership in Clinical Trials or CBPR", "description": "MIPS eligible clinician leadership in clinical trials, research alliances or community-based participatory research (CBPR) that identify tools, research or processes that can focuses on minimizing disparities in healthcare access, care quality, affordability, or outcomes.", "measureId": "IA_AHE_5", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "achievingHealthEquity" }, { "category": "ia", "title": "Provide Education Opportunities for New Clinicians", "description": "MIPS eligible clinicians acting as a preceptor for clinicians-in-training (such as medical residents/fellows, medical students, physician assistants, nurse practitioners, or clinical nurse specialists) and accepting such clinicians for clinical rotations in community practices in small, underserved, or rural areas.", "measureId": "IA_AHE_6", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "achievingHealthEquity" }, { "category": "ia", "title": "Comprehensive Eye Exams", "description": "In order to receive credit for this activity, MIPS eligible clinicians must promote the importance of a comprehensive eye exam, which may be accomplished by providing literature and/or facilitating a conversation about this topic using resources such as the \"Think About Your Eyes\" campaign72 and/or referring patients to resources providing no-cost eye exams, such as the American Academy of Ophthalmology's EyeCare America73 and the American Optometric Association's VISION USA74. This activity is intended for: (1) non- ophthalmologists / optometrist who refer patients to an ophthalmologist/optometrist; (2) ophthalmologists/optometrists caring for underserved patients at no cost; or (3) any clinician providing literature and/or resources on this topic. This activity must be targeted at underserved and/or high- risk populations that would benefit from engagement regarding their eye health with the aim of improving their access to comprehensive eye exams.", "measureId": "IA_AHE_7", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "achievingHealthEquity" }, { "category": "ia", "title": "Participation on Disaster Medical Assistance Team, registered for 6 months.", "description": "Participation in Disaster Medical Assistance Teams, or Community Emergency Responder Teams. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and MIPS eligible clinician groups must be registered for a minimum of 6 months as a volunteer for disaster or emergency response.", "measureId": "IA_ERP_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "emergencyResponseAndPreparedness" }, { "category": "ia", "title": "Participation in a 60-day or greater effort to support domestic or international humanitarian needs.", "description": "Participation in domestic or international humanitarian volunteer work. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and groups attest to domestic or international humanitarian volunteer work for a period of a continuous 60 days or greater.", "measureId": "IA_ERP_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "emergencyResponseAndPreparedness" }, { "category": "ia", "title": "Diabetes screening", "description": "Diabetes screening for people with schizophrenia or bipolar disease who are using antipsychotic medication.", "measureId": "IA_BMH_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "behavioralAndMentalHealth" }, { "category": "ia", "title": "Tobacco use", "description": "Tobacco use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including tobacco use screening and cessation interventions (refer to NQF #0028) for patients with co-occurring conditions of behavioral or mental health and at risk factors for tobacco dependence.", "measureId": "IA_BMH_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "behavioralAndMentalHealth" }, { "category": "ia", "title": "Unhealthy alcohol use", "description": "Unhealthy alcohol use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including screening and brief counseling (refer to NQF #2152) for patients with co-occurring conditions of behavioral or mental health conditions.", "measureId": "IA_BMH_3", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "behavioralAndMentalHealth" }, { "category": "ia", "title": "Depression screening", "description": "Depression screening and follow-up plan: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including depression screening and follow-up plan (refer to NQF #0418) for patients with co-occurring conditions of behavioral or mental health conditions.", "measureId": "IA_BMH_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "behavioralAndMentalHealth" }, { "category": "ia", "title": "MDD prevention and treatment interventions", "description": "Major depressive disorder: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including suicide risk assessment (refer to NQF #0104) for mental health patients with co-occurring conditions of behavioral or mental health conditions.", "measureId": "IA_BMH_5", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "behavioralAndMentalHealth" }, { "category": "ia", "title": "Implementation of co-location PCP and MH services", "description": "Integration facilitation and promotion of the colocation of mental health and substance use disorder services in primary and/or non-primary clinical care settings.", "measureId": "IA_BMH_6", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "behavioralAndMentalHealth" }, { "category": "ia", "title": "Implementation of Integrated Patient Centered Behavioral Health Model", "description": "Offer integrated behavioral health services to support patients with behavioral health needs who also have conditions such as dementia or other poorly controlled chronic illnesses. The services could include one or more of the following: - Use evidence-based treatment protocols and treatment to goal where appropriate;- Use evidence-based screening and case finding strategies to identify individuals at risk and in need of services;- Ensure regular communication and coordinated workflows between MIPS eligible clinicians in primary care and behavioral health;- Conduct regular case reviews for at-risk or unstable patients and those who are not responding to treatment;- Use of a registry or health information technology functionality to support active care management and outreach to patients in treatment;- Integrate behavioral health and medical care plans and facilitate integration through co-location of services when feasible; and/or- Participate in the National Partnership to Improve Dementia Care Initiative, which promotes a multidimensional approach that includes public reporting, state-based coalitions, research, training, and revised surveyor guidance.", "measureId": "IA_BMH_7", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "behavioralAndMentalHealth" }, { "category": "ia", "title": "Electronic Health Record Enhancements for BH data capture", "description": "Enhancements to an electronic health record to capture additional data on behavioral health (BH) populations and use that data for additional decision-making purposes (e.g., capture of additional BH data results in additional depression screening for at-risk patient not previously identified).", "measureId": "IA_BMH_8", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "behavioralAndMentalHealth" }, { "category": "ia", "title": "Unhealthy Alcohol Use for Patients with Co-occurring Conditions of Mental Health and Substance Abuse and Ambulatory Care Patients", "description": "Individual MIPS eligible clinicians or groups must regularly engage in integrated prevention and treatment interventions, including screening and brief counseling (for example: NQF #2152) for patients with co-occurring conditions of mental health and substance abuse. MIPS eligible clinicians would attest that 60 percent for the CY 2018 Quality Payment Program performance period, and 75 percent beginning in the 2019 performance period, of their ambulatory care patients are screened for unhealthy alcohol use.", "measureId": "IA_BMH_9", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "behavioralAndMentalHealth" }, { "category": "ia", "title": "Completion of Collaborative Care Management Training Program", "description": "In order to receive credit for this activity, MIPS eligible clinicians must complete a collaborative care management training program, such as the American Psychological Association (APA) Collaborative Care Model training program available as part of the Centers for Medicare & Medicaid Services (CMS) Transforming Clinical Practice Initiative (TCPI)75, available to the public 76, in order to implement a collaborative care management approach that provides comprehensive training in the integration of behavioral health into the primary care practice.", "measureId": "IA_BMH_10", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "behavioralAndMentalHealth" }, { "category": "ia", "title": "Electronic submission of Patient Centered Medical Home accreditation", "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.", "measureId": "IA_PCMH", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": null, "subcategoryId": null }, { "category": "cost", "title": "Elective Outpatient Percutaneous Coronary Intervention (PCI)", "description": "A clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo elective outpatient PCI surgery to place a coronary stent for heart disease during the performance period. Includes costs of services clinically related to the attributed clinician’s role in managing care from the PCI surgery that triggers the episode through 30 days after the trigger.", "measureId": "COST_EOPCI_1", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": null, "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "measureInformation": "https://qpp.cms.gov/docs/cost_specifications/2018-12-21-mif-ebcm-op-pci.pdf", "codeList": "https://qpp.cms.gov/docs/cost_specifications/2018-12-21-codes-list-op-pci.xlsx", "changeLog": "https://qpp.cms.gov/docs/cost_specifications/2019-11-11-changelog-op-pci.pdf" } }, { "category": "cost", "title": "Revascularization for Lower Extremity Chronic Critical Limb Ischemia", "description": "A clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo elective revascularization surgery for lower extremity chronic critical limb ischemia during the performance period. Includes costs of services that are clinically related to the attributed clinician’s role in managing care from 30 days prior to the revascularization procedure that triggers the episode through 90 days after the trigger.", "measureId": "COST_CCLI_1", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": null, "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "measureInformation": "https://qpp.cms.gov/docs/cost_specifications/2018-12-21-mif-ebcm-rleccli.pdf", "codeList": "https://qpp.cms.gov/docs/cost_specifications/2018-12-21-codes-list-rleccli.xlsx", "changeLog": "https://qpp.cms.gov/docs/cost_specifications/2019-11-11-changelog-rleccli.pdf" } }, { "category": "cost", "title": "Simple Pneumonia with Hospitalization", "description": "A clinician’s risk-adjusted cost to Medicare for beneficiaries hospitalized with simple pneumonia during the performance period. Includes costs of services that are clinically related to the attributed clinician’s role in managing care from the inpatient hospitalization that triggers the episode through 30 days after the trigger.", "measureId": "COST_SPH_1", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": null, "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "measureInformation": "https://qpp.cms.gov/docs/cost_specifications/2018-12-21-mif-ebcm-pna-hosp.pdf", "codeList": "https://qpp.cms.gov/docs/cost_specifications/2018-12-21-codes-list-pna-hosp.xlsx", "changeLog": "https://qpp.cms.gov/docs/cost_specifications/2019-11-11-changelog-pna-hosp.pdf" } }, { "category": "cost", "title": "Screening/Surveillance Colonoscopy", "description": "A clinician’s risk-adjusted cost to Medicare for beneficiaries who receive a screening/surveillance colonoscopy. Includes costs of services that are clinically related to the attributed clinician’s role in managing care from the screening/surveillance colonoscopy procedure that triggers the episode through 14 days after the trigger.", "measureId": "COST_SSC_1", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": null, "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "measureInformation": "https://qpp.cms.gov/docs/cost_specifications/2018-12-21-mif-ebcm-ss-clnscpy.pdf", "codeList": "https://qpp.cms.gov/docs/cost_specifications/2018-12-21-codes-list-ss-clnscpy.xlsx", "changeLog": "https://qpp.cms.gov/docs/cost_specifications/2019-11-11-changelog-ss-clnscpy.pdf" } }, { "category": "cost", "title": "Knee Arthroplasty", "description": "A clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo an elective knee arthroplasty during the performance period. Includes costs of services clinically related to the attributed clinician’s role in managing care from 30 days prior to the knee arthroplasty that triggers the episode through 90 days after the trigger.", "measureId": "COST_KA_1", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": null, "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "measureInformation": "https://qpp.cms.gov/docs/cost_specifications/2018-12-21-mif-ebcm-knee-arthro.pdf", "codeList": "https://qpp.cms.gov/docs/cost_specifications/2018-12-21-codes-list-knee-arthro.xlsx", "changeLog": "https://qpp.cms.gov/docs/cost_specifications/2019-11-11-changelog-knee-arthro.pdf" } }, { "category": "cost", "title": "Routine Cataract Removal with Intraocular Lens (IOL) Implantation", "description": "A clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo a procedure for routine cataract removal with IOL implantation during the performance period. Includes costs of services that are clinically related to the attributed clinician’s role in managing care from 60 days prior to the cataract removal procedure that triggers the episode through 90 days after the trigger.", "measureId": "COST_IOL_1", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": null, "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "measureInformation": "https://qpp.cms.gov/docs/cost_specifications/2018-12-21-mif-ebcm-cataract.pdf", "codeList": "https://qpp.cms.gov/docs/cost_specifications/2018-12-21-codes-list-cataract.xlsx", "changeLog": "https://qpp.cms.gov/docs/cost_specifications/2019-11-11-changelog-cataract.pdf" } }, { "category": "cost", "title": "Intracranial Hemorrhage or Cerebral Infarction", "description": "A clinician’s risk-adjusted cost to Medicare for beneficiaries hospitalized for cerebral infarction or intracranial hemorrhage during the performance period. Includes costs of services clinically related to the attributed clinician’s role in managing care from the inpatient hospitalization that triggers the episode through 90 days after the trigger.", "measureId": "COST_IHCI_1", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": null, "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "measureInformation": "https://qpp.cms.gov/docs/cost_specifications/2018-12-21-mif-ebcm-ich-cva.pdf", "codeList": "https://qpp.cms.gov/docs/cost_specifications/2018-12-21-codes-list-ich-cva.xlsx", "changeLog": "https://qpp.cms.gov/docs/cost_specifications/2019-11-11-changelog-ich-cva.pdf" } }, { "category": "cost", "title": "ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI)", "description": "A clinician’s risk-adjusted cost to Medicare for beneficiaries who present with STEMI, indicating complete blockage of a coronary artery, who emergently receive PCI as treatment during the performance period. Includes costs of services that are clinically related to the attributed clinician’s role in managing care from the inpatient hospitalization that triggers the episode through 30 days after the trigger.", "measureId": "COST_STEMI_1", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": null, "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "measureInformation": "https://qpp.cms.gov/docs/cost_specifications/2018-12-21-mif-ebcm-stemi-pci.pdf", "codeList": "https://qpp.cms.gov/docs/cost_specifications/2018-12-21-codes-list-stemi-pci.xlsx", "changeLog": "https://qpp.cms.gov/docs/cost_specifications/2019-11-11-changelog-stemi-pci.pdf" } }, { "category": "cost", "title": "Medicare Spending Per Beneficiary (MSPB)", "description": "The risk-adjusted cost to Medicare for all Parts A and B services performed for an inpatient beneficiary as a result of a clinician’s care during the period 3 days prior to the patient’s hospital stay through 30 days after discharge.", "measureId": "MSPB_1", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "measureInformation": "https://qpp.cms.gov/docs/cost_specifications/2019-04-16-mif-mspb.pdf" } }, { "category": "cost", "title": "Total Per Capita Costs (TPCC)", "description": "The overall, payment-standardized, annualized, risk-adjusted, and specialty-adjusted cost of care provided to beneficiaries attributed to their primary care clinicians.", "measureId": "TPCC_1", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "measureInformation": "https://qpp.cms.gov/docs/cost_specifications/2018-12-21-mif-tpcc.pdf" } }, { "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", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAAAI QCDR - American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by ArborMetrix", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "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", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAAAI QCDR - American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by ArborMetrix", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "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", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAAAI QCDR - American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by ArborMetrix", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "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", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAAAI QCDR - American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by ArborMetrix", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "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", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAAAI QCDR - American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by ArborMetrix", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "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", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAAAI QCDR - American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by ArborMetrix", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "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", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAAAI QCDR - American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by ArborMetrix", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "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", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAAAI QCDR - American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by ArborMetrix", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAD2", "title": "Psoriasis: Screening for Psoriatic Arthritis", "description": "Percentage of patients with diagnosis of psoriasis that are screened for psoriatic arthritis at least once during the performance period.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAD'S DataDerm", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAD5", "title": "Biopsy: Reporting Time - Clinician to Patient", "description": "Percentage of patients with skin biopsy specimens with a diagnosis of cutaneous basal or squamous cell carcinoma (including in situ disease) who are notified of their final biopsy pathology findings within less than or equal to 14 days from the time the biopsy was performed.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAD'S DataDerm", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACMS1", "title": "Adherence to Mohs Micrographic Surgery Appropriate Use Criteria", "description": "Percentage of Mohs micrographic surgery cases that meet criteria according to published Mohs surgery appropriate use criteria (AUC) guidelines.", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MohsAIQ", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAPMR1", "title": "Assessment and Management of Muscle Spasticity--Inpatient", "description": "Percentage of patients, regardless of age with a diagnosis of stroke, acquired brain injury (ABI), spinal cord injury (SCI), cerebral palsy (CP), or multiple sclerosis (MS) who are admitted to inpatient rehabilitation, skilled nursing facility, or long-term care hospital with a documented assessment of muscle spasticity AND if muscle spasticity is present, a plan of care to monitor and/or manage muscle spasticity is documented prior to discharge\n\nThree rates are reported:\nRate 1: Percentage of patients, regardless of age with a diagnosis of stroke, acquired brain injury (ABI), spinal cord injury (SCI), cerebral palsy (CP), or multiple sclerosis (MS) who are admitted to inpatient rehabilitation, skilled nursing facility, or long-term care hospital with a documented assessment of muscle spasticity prior to discharge\n\nRate 2: Percentage of patients regardless of age with a diagnosis of stroke, acquired brain injury (ABI), spinal cord injury (SCI), cerebral palsy (CP), or multiple sclerosis (MS) who are admitted to inpatient rehabilitation, skilled nursing facility, or long-term care hospital with muscle spasticity who have a documented plan of care to monitor and/or manage muscle spasticity prior to discharge.\n\nRate 3: Percentage of patients, regardless of age with a diagnosis of stroke, acquired brain injury (ABI), spinal cord injury (SCI), cerebral palsy (CP), or multiple sclerosis (MS) who are admitted to inpatient rehabilitation, skilled nursing facility, or long-term care hospital with a documented assessment of muscle spasticity AND if muscle spasticity is present, a plan of care to monitor and/or manage muscle spasticity is documented prior to discharge\n\n-It is expected that population Criteria 1 and 3 should be submitted on all patients. Population Criteria 2 could only be reported for those patients who were identified as having muscle spasticity who have a documented plan of care to monitor and/or manage muscle spasticity prior to discharge.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAPM&R's Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "assessment", "description": "Percentage of patients, regardless of age with a diagnosis of stroke, acquired brain injury (ABI), spinal cord injury (SCI), cerebral palsy (CP), or multiple sclerosis (MS) who are admitted to inpatient rehabilitation, skilled nursing facility, or long-term care hospital with a documented assessment of muscle spasticity prior to discharge" }, { "name": "plan", "description": "Percentage of patients regardless of age with a diagnosis of stroke, acquired brain injury (ABI), spinal cord injury (SCI), cerebral palsy (CP), or multiple sclerosis (MS) who are admitted to inpatient rehabilitation, skilled nursing facility, or long-term care hospital with muscle spasticity who have a documented plan of care to monitor and/or manage muscle spasticity prior to discharge." }, { "name": "overall", "description": "Percentage of patients, regardless of age with a diagnosis of stroke, acquired brain injury (ABI), spinal cord injury (SCI), cerebral palsy (CP), or multiple sclerosis (MS) who are admitted to inpatient rehabilitation, skilled nursing facility, or long-term care hospital with a documented assessment of muscle spasticity AND if muscle spasticity is present, a plan of care to monitor and/or manage muscle spasticity is documented prior to discharge" } ], "submissionMethods": [ "registry" ] }, { "measureId": "AAPMR2", "title": "Management of Muscle Spasticity--Outpatient", "description": "Percentage of patients, regardless of age with a diagnosis of stroke, acquired brain injury (ABI), spinal cord injury (SCI), cerebral palsy (CP), or multiple sclerosis (MS) with muscle spasticity, who are seen for an office visit during the measurement period with a documented plan of care to monitor and/or manage muscle spasticity", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAPM&R's Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAPMR3", "title": "Functional Assessment to Determine Rehabilitation Needs", "description": "Percentage of patients aged 18 and older who have experienced a stroke or acute brain injury (ischemic stroke, hemorrhagic stroke, acute brain injury) and are admitted to acute care who have a comprehensive functional assessment to determine rehabilitation needs performed prior to discharge.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAPM&R's Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAPMR4", "title": "Family Training-Inpatient Rehabilitation/Skilled Nursing Facility-Discharged to Home", "description": "Percentage of patients aged 18 years and older who have experienced a stroke or acute brain injury (ischemic stroke, hemorrhagic stroke, acture brain injury) discharged from inpatient rehabilitation, skilled nursing facility, or long-term care hospital to home, whose family/caregiver(s) demonstrated successful teach-back regarding skills for care of the patient in the home setting", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAPM&R's Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAPMR5", "title": "Post-Acute Brain Injury: Depression Screening and Follow-Up Plan of Care", "description": "Percentage of patients aged 18 years and older who have experienced an acute brain injury (ischemic stroke, hemorrhagic stroke, acute brain injury), seen for an office visit during the measurement period who were screened for depression using a validated tool and if screened positive AND if positive, a follow up plan of care is documented on the date of the positive screen", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AAPM&R's Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPA24", "title": "Narcotic Pain Medicine Management Following Elective Spine Procedure", "description": "Percentage of patients aged 18 years and older with documentation of narcotic use/requirements at baseline (initial encounter) and at 3 months following initial assessment and interventions for treatment of spine-related pain symptoms and documentation of follow-up plan.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Quality Outcomes Database (QOD)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPA25", "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.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Quality Outcomes Database (QOD)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPA26", "title": "Functional Outcome Assessment for Spine Intervention", "description": "Percentage of patients aged 18 years and older undergoing spine intervention(s) 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. \nOverall Rate = Rate 2", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Quality Outcomes Database (QOD)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "baseline", "description": "Patient population with Follow-up/Patient population with baseline" }, { "name": "overall", "description": "Patient population with improvement in functional status after Follow-up/Patient population with Follow-up." } ], "submissionMethods": [ "registry" ] }, { "measureId": "NPA27", "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 initial assessment and intervention(s) for treatment of spine-related pain symptoms with at least 10% improvement in the pain status from the baseline and documentation of follow-up plan. This measure will be calculated with 2 performance rates:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in pain status after Follow-up/Patient population with Follow-up. \nOverall Rate = Rate 2", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Quality Outcomes Database (QOD)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "baseline", "description": "Patient population with Follow-up/Patient population with baseline" }, { "name": "overall", "description": "Patient population with improvement in pain status after Follow-up/Patient population with Follow-up." } ], "submissionMethods": [ "registry" ] }, { "measureId": "NPA28", "title": "Patient Satisfaction With Spine Care", "description": "Percentage of patients aged 18 years and older undergoing spine intervention(s) 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. \nOverall Rate = Rate 2", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Quality Outcomes Database (QOD)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "baseline", "description": "Patient population with Follow-up/Patient population with baseline" }, { "name": "overall", "description": "Patient population with improvement in satisfaction with care status after Follow-up/Patient population with Follow-up." } ], "submissionMethods": [ "registry" ] }, { "measureId": "NPA29", "title": "Quality-of-Life Assessment for Spine Intervention", "description": "Percentage of patients aged 18 years and older undergoing index spine intervention(s) 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. \nOverall Rate = Rate 2", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Quality Outcomes Database (QOD)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "baseline", "description": "Patient population with Follow-up/Patient population with baseline" }, { "name": "overall", "description": "Patient population with improvement in quality of life status after Follow-up/Patient population with Follow-up." } ], "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.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "AAPM&R's Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPAGSC9", "title": "Unplanned Admission to Hospital Following Percutaneous Spine Procedure within the 30-Day Post-procedure Period", "description": "Percentage of patients aged 18 years and older who had any unplanned admission following percutaneous spine-related procedure within the 30-day post-procedure period", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "AAPM&R's Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABFM2", "title": "Patients Admitted to ICU who Have Care Preferences Documented", "description": "Percentage of adult 18 and older patients admitted to ICU who receive palliative care and survive at least 2 days who have their care preferences documented within 2 days OR documentation as to why this was not done.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABFM PRIME", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABFM3", "title": "Patients Treated with an Opioid Who Are Given a Bowel Regimen", "description": "Percentage of adults 18 and older treated with an opioid that are offered/prescribed a bowel regimen during the same visit or documentation of reason for why this was not needed", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABFM PRIME", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABFM5", "title": "Palliative Care-Treatment Preferences", "description": "The percentage of adult patients 18 and older with documentation of preferences for life-sustaining treatments within the first three visits", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABFM PRIME", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABFM6", "title": "Palliative Care Timely Dyspnea Screening & Treatment", "description": "Percentage of palliative care adult patients 18 years and older who were screened for dyspnea during the initial palliative care encounter or documentation that a screening was attempted AND for those with moderate/severe dyspnea or who are uncomfortable due to dyspnea who receive treatment within 1 day of screening.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABFM PRIME", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABFM7", "title": "Pain Brought Under Control within the first three visits", "description": "Percent of patients 18 and older who report being uncomfortable because of pain at the initial palliative care assessment who report pain was brought to a comfortable level (e.g. \"Comfortable? Yes/No\", \"mild\" or pain score < 4) within the first three visits", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABFM PRIME", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABFM8", "title": "Measuring the Value-Functions of Primary Care: Provider Level Continuity Measure", "description": "Bice-Boxerman Continuity of Care Primary Care Physician Measure (BB-COC-PC). \n\nAt a patient-level, BB-COC is a measure that considers the dispersion of primary care visits across providers, such that patients with higher scores have most of their primary care visits to the same provider or a small number of providers while those lower scores see a larger number providers. Formally, an individual BB-COC score is calculated as follows:\n\nBB-COC=(∑_(i=1)^k n_i^2 -N)/(N(N-1)) (1)\n\nwhere k is the number of providers, n_i is the number of visits to provider i, and N is the total number of visits. (Note that it is necessary that the patient has at least two visits.)\nWe will calculate the physician-level continuity measure for all patients as follows: \n \nBB-COC-PC=(∑_1^k _((BB-COC)(n_k ))_)/(N*(n_k)) (2)\n\nWhere BB-COC is the individual patient continuity score, n is number of total primary care visits for patient k during the study period, and N is the total number of patients seen by the physicians during the study period. This approach gives greater weight to patients with more visits.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "structure", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABFM PRIME", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABG16", "title": "Planned use of difficult airway equipment", "description": "For all patients on whom difficult airway equipment is used in the operating room/procedure room during an anesthetic, the rate with which it's use is planned ahead of time for either therapeutic or educational purposes. \n\nThe definition of difficult airway equipment for this measure excludes stylets and/or bougies unless they have been modified to include a light source or some other mechanical addition to manipulate their placement.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABG QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABG34", "title": "Mood Assessment Screening and treatment", "description": "Percentage of patients with a diagnosis of chronic pain who were assessed for depression and anxiety with a standardized tool at least twice in the calendar year and who are treated for mood disorders during the calendar year as a result of their elevated assessment scores.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABG QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABG37", "title": "Preoperative Screening for Anesthetic Risk Factors", "description": "Percentage of patients, regardless of age, undergoing a surgical, therapeutic or diagnostic procedures under anesthesia in an operating/procedure room during the performance period and who have a documented use of a pre-operative assessment of two or more anesthetic risk factors prior to the start of anesthesia and the procedure did not result in an impairment of anesthesia or the patient did not experience a decrease in the effectiveness of anesthesia. Risk factor assessment must include at least two of the following: \n\n-\tSymptoms of Gastroesophageal Reflux Disease\n-\t History of Glaucoma or elevated eye pressures\n-\tPost-operative Nausea and Vomiting risk factors\n-\tAlcohol and recreational drug use\n-\tHerbal supplements and antibiotic impairment of anesthesia", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABG QCDR, SCG Health", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABG38", "title": "Second provider present for induction/intubation of known or suspected difficult airway", "description": "In adult patients with a known or suspected difficult airway, presence of a dedicated second provider at induction of general endotracheal anesthesia who can serve as an assistant for management of a difficult airway.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABG QCDR", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABG39", "title": "Preoperative Active Warming", "description": "Percentage of patients, aged 18 years and older who present for colorectal surgery with regional or general anesthesia who have core temperatures checked preoperatively within one hour prior to induction of anesthesia and, when less than 36C, have active warming measures applied.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABG QCDR", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ABG7", "title": "Immediate Adult Post-Operative Pain Management", "description": "The percentage of patients 18 or older admitted to the PACU after an anesthetic with a maximum pain score <7/10 prior to anesthesia end time.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABG QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI48", "title": "Patient-Reported Experience with Anesthesia", "description": "Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care and who reported a positive experience. \n\nThis measure will consist of two performance rates:\n\nRate 1: AQI48a: Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care \nRate 2: AQI48b: Percentage of patients, aged 18 and older, who completed a survey on their patient experience and satisfaction with anesthesia care who report a positive experience with anesthesia care\n\nNOTE: The measure requires that a valid survey, as defined in the numerator, be sent to patients between discharge from the facility and within 30 days of facility discharge. To report AQI 48b, a minimum number of 20 surveys with the mandatory question completed must be reported.", "nqfId": null, "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)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "surveyed", "description": "AQI48a: Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care" }, { "name": "overall", "description": "AQI48b: Percentage of patients, aged 18 and older, who completed a survey on their patient experience and satisfaction with anesthesia care who report a positive experience with anesthesia care" } ], "submissionMethods": [ "registry" ] }, { "measureId": "AQI55", "title": "Team-Based Implementation of a Care-and-Communication Bundle for ICU Patients", "description": "Percentage of patients, regardless of age, who are admitted to an intensive care unit (ICU) for >=48 hours and who received critical care services who have documentation by managing physician of 1) attempted or actual identification of a surrogate decision maker, 2) an advance directive, and 3) the patient's preference for cardiopulmonary resuscitation, within 48 hours of ICU admission", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI56", "title": "Use of Neuraxial Techniques and/or Peripheral Nerve Blocks for Total Knee Arthroplasty (TKA)", "description": "Percentage of patients, regardless of age, that undergo primary total knee arthroplasty for whom neuraxial anesthesia and/or a peripheral nerve block is performed", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI57", "title": "Safe Opioid Prescribing Practices", "description": "Percentage of patients, aged 18 years and older, prescribed opioid medications for longer than six weeks' duration for whom ALL of the following opioid prescribing best practices are followed:\n\n1. Chemical dependency screening (includes laboratory testing and/or questionnaire) within the immediate 6 months prior to the encounter\n2. Co-prescription of naloxone or documented discussion regarding offer of Naloxone co-prescription, if prescription is >=50 MME/day\n3. Non co-prescription of benzodiazepine medications by prescribing pain physician and documentation of a discussion with patient regarding risks of concomitant use of benzodiazepine and opioid medications.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI58", "title": "Infection Control Practices for Open Interventional Pain Procedures", "description": "Percentage of patients, regardless of age, that undergo an open interventional pain procedure for whom ALL of the following infection control best practices are followed by anesthesiologist(s) and scrub technologist(s), in addition to standard sterile technique: \n1. Double gloving (two pairs of sterile gloves are worn)\n2. Chlorhexidine with alcohol used for surgical site preparation\n3. Weight-based preoperative antibiotic dosing and, if indicated by procedure duration, weight-based re-dosing\n4. Administration of pre-operative antibiotics within 1 hour, or 2 hours for vancomycin, prior to surgical incision", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI59", "title": "Multimodal Pain Management", "description": "Percentage of patients, regardless of age, undergoing selected elective surgical procedures that were managed with multimodal pain medicine.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI61", "title": "Ambulatory Post-Discharge Patient Follow-Up", "description": "Percentage of patients, regardless of age, who received anesthesia services in an ambulatory setting whose post-discharge status was assessed within 72 hours of discharge", "nqfId": null, "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)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI62", "title": "Obstructive Sleep Apnea: Patient Education", "description": "Percentage of patients aged 18 years or older, who undergo an elective procedure requiring anesthesia services who are screened for obstructive sleep apnea (OSA) AND, if positive, have documentation that they received education regarding their risk for OSA prior to PACU discharge", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI63", "title": "Neuromuscular Blockade: Documented Assessment of Neuromuscular Function Prior to Extubation", "description": "Percentage of patients requiring anesthesia services with a documented assessment of neuromuscular blockade reversal after last dose of non-depolarizing neuromuscular blocker", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI64", "title": "Neuromuscular Blockade: Reversal Administered", "description": "Percentage patients aged 12 years and older, requiring anesthesia services where nondepolarizing neuromuscular blockade is used and neostigmine, sugammadex, and/or edrophonium are administered prior to extubation", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI66", "title": "Obstructive Sleep Apnea: Mitigation Strategies", "description": "Percentage of patients aged 18 years or older, who undergo an elective procedure requiring anesthesia services who are screened for obstructive sleep apnea (OSA) AND, if positive, for whom two or more selected mitigation strategies was used prior to PACU discharge", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI67", "title": "Consultation for Frail Patients", "description": "Percentage of patients aged 70 years or older, who undergo an inpatient procedure requiring anesthesia services and have a positive frailty screening result who receive a multidisciplinary consult or care during the hospital encounter", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP19", "title": "Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older", "description": "Percentage of emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP20", "title": "Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years", "description": "Percentage of emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the PECARN prediction rules for traumatic brain injury", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP21", "title": "Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or Bleeding", "description": "Percentage of emergency department visits for patients aged 18 years and older with an emergency department discharge diagnosis of chest pain during which coagulation studies were ordered by an emergency care provider", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP22", "title": "Appropriate Emergency Department Utilization of CT for Pulmonary Embolism", "description": "Percentage of emergency department visits during which patients aged 18 years and older had a CT pulmonary angiogram (CTPA) ordered by an emergency care provider, regardless of discharge disposition, with either moderate or high pre-test clinical probability for pulmonary embolism OR positive result or elevated D-dimer level", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP25", "title": "Tobacco Use: Screening and Cessation Intervention for Patients with Asthma and COPD", "description": "Percentage of patients aged 18 years and older with a diagnosis of asthma or COPD seen in the ED who were screened for tobacco use during any ED encounter AND who received tobacco cessation intervention if identified as a tobacco user", "nqfId": null, "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP30", "title": "Sepsis Management: Septic Shock: Lactate Clearance Rate of >= 10%", "description": "Percentage of emergency department visits for patients aged 18 years and older with septic shock who had an elevated serum lactate result (>2mmol/L) and a subsequent serum lactate level measurement performed following the elevated serum lactate result with a lactate clearance rate of >= 10% during the emergency department visit", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP31", "title": "Appropriate Foley catheter use in the emergency department", "description": "Percentage of emergency department (ED) visits for admitted patients aged 18 years and older where an indwelling Foley catheter is ordered and the patient had at least one indication for an indwelling Foley catheter", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP48", "title": "Sepsis Management: Septic Shock: Lactate Level Measurement, Antibiotics Ordered, and Fluid Resuscitation", "description": "Percentage of emergency department visits resulting in hospital admission for patients aged 18 years and older with septic shock who had an order for all the following during the emergency department visit: a serum lactate level, antibiotics, and >1L of crystalloids", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP50", "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients", "description": "Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP51", "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients", "description": "Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACQR10", "title": "Syncope: complete evaluation", "description": "Patients admitted to observation or inpatient status for syncope should have an initial evaluation including a thorough history, 12 lead EKG, and orthostatic vital signs", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "efficiency", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Acute Care Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACQR11", "title": "High Intensity Statin for patients with NSTEMI-ACS", "description": "High intensity statin (rosuvastatin 20-40 mg or atorvastatin 80mg) should be initiated or continued in all patients with NSTEMI-ACS and no contraindications", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "efficiency", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Acute Care Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACQR12", "title": "ABCDEF Bundle - Early mobility for ICU patients", "description": "Patients admitted to the intensive care unit (ICU) for > or = 4 days should be included in an early mobility program (E of ABCDEF Bundle) to improve their recovery process.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Acute Care Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACQR13", "title": "Sepsis: Hour One bundle", "description": "Surviving Sepsis Campaign's Hour One bundle initiation in patients with Sepsis and acute organ dysfunction", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "efficiency", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Acute Care Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACQR14", "title": "Use of HEART score for risk stratification in patients with suspected NSTEMI-ACS", "description": "Documentation of risk stratification (i.e. HEART score or TIMI) in patients with suspected Non ST segment Elevation Myocardial Infarction and/or Acute Coronary Syndrome", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Acute Care Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACQR15", "title": "Pneumonia: Use of CURB-65 for Risk Stratification in patient with CAP", "description": "Documentation of CURB-65 score should guide the admission decision (1 point each for Confusion, BUN>19, Resp rate >30, SBP <90 or DBP<60, Age >=65) for all patients with Community Acquired Pneumonia)", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Acute Care Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACQR16", "title": "COPD Exacerbation or CHF Exacerbation requiring Hospital Admission: Palliative Care Evaluation", "description": "Patients admitted with 2 or more COPD exacerbations in 12 months or a single admission for COPD with hypercapneic respiratory failure, or being discharged to a SNF or LTACH should receive an evaluation from a palliative care professional, if available; and patients admitted with AHA Class D heart failure and/or patients admitted with Congestive Heart Failure (any class) being discharged to a SNF or LTACH should receive an evaluation from a palliative care professional, if available", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "efficiency", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Acute Care Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACQR3", "title": "COPD: Steroids for no more than 5 days in COPD Exacerbation", "description": "Patients should receive no more than 5 days of steroids in treatment for COPD Exacerbation from all sources and routes. Sources may include outpatient, Emergency Department, and Inpatient/Observation treatment. i.e. Full course of steroids not to exceed 7 days.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "efficiency", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Acute Care Quality Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACQR7", "title": "Sepsis Management: Septic Shock: Repeat Lactate Measurement Level Within 6 Hours", "description": "Percentage of patients aged 18 years or greater admitted with septic shock and an elevated serum lactate result (>4 mmol/L) with a second serum lactate measurement ordered following the initial elevated result", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "efficiency", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Acute Care Quality Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACQR9", "title": "Use of ACE-I or ARB and beta blockade in CHF", "description": "Ace I or ARBs AND 1 of [3 beta blockers proven to reduce mortality] (bisoprolol, carvedilol, sustained release metoprolol) are recommended in HFrEF and current or prior symptoms of CHF", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "efficiency", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Acute Care Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MA1", "title": "Case Delay", "description": "Percentage of anesthesia cases or procedures which are delayed greater than 15 minutes after the scheduled start with a reason indicated\nPerformance rates: - Rate 1: Advance 3B: Procedure delayed from scheduled start time; Rate 2: Advance 3C: Reason for delay indicated", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "MiraMed, Advance QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "delayed", "description": "Advance 3B: Procedure delayed from scheduled start time;" }, { "name": "overall", "description": "Advance 3C: Reason for delay indicated" } ], "submissionMethods": [ "registry" ] }, { "measureId": "AHSQC10", "title": "Ventral Hernia Repair: Pain and Functional Status Assessment", "description": "Percentage of patients aged 18 years and older who have undergone ventral hernia repair and who completed baseline and 30 day follow-up patient-reported functional status assessments, and achieved at least a 10% improvement in functional status score from baseline.\nPerformance Rates:\nRate 1: Patients who achieved at least a 10% improvement in functional status score from baseline.\nRate 2: Patients who completed baseline and 30 day follow-up patient-reported functional status assessments.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AHSQC", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "overall", "description": "Patients who achieved at least a 10% improvement in functional status score from baseline." }, { "name": "followup", "description": "Patients who completed baseline and 30 day follow-up patient-reported functional status assessments." } ], "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", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "AHSQC", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "overall", "description": "Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Any hernia width (overall rate)" }, { "name": "<=10cm", "description": "Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of <=10cm" }, { "name": ">10cm", "description": "Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of >10cm" } ], "submissionMethods": [ "registry" ] }, { "measureId": "IRIS1", "title": "Endothelial Keratoplasty - Post-operative improvement in best corrected visual acuity to 20/40 or better", "description": "Percentage of endothelial keratoplasty patients with a best corrected visual acuity of 20/40 or better at 90 days after surgery", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS13", "title": "Diabetic Macular Edema - Loss of Visual Acuity", "description": "Percentage of patients with a diagnosis of diabetic macular edema with a loss of less than 3 Snellen lines (which is equivalent to less than 0.3 logMAR) within the past 12 months.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS18", "title": "Chronic Anterior Uveitis - Post-treatment visual acuity", "description": "Percentage of chronic anterior uveitis patients with a post-treatment best corrected visual acuity of 20/40 or better or patients whose visual acuity had returned to their baseline value prior to onset of uveitis.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS2", "title": "Glaucoma - Intraocular Pressure (IOP) Reduction", "description": "Percentage of glaucoma patient visits where their IOP was below a threshold level based on the severity of their diagnosis.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "intermediateOutcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS21", "title": "Ocular Myasthenia Gravis: Improvement of ocular deviation or absence of diplopia or functional improvement", "description": "Percentage of patients with a diagnosis of ocular myasthenia gravis who had an improvement of ocular deviation or were absent of diplopia in primary gaze or had functional improvement of ptosis 6 months after initial treatment.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS22", "title": "Giant Cell Arteritis: Absence of fellow eye involvement after treatment", "description": "Percentage of patients without fellow eye involvement 1-26 weeks after initiating treatment in patients with unilateral visual loss.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS23", "title": "Refractive Surgery: Patients with a postoperative uncorrected visual acuity (UCVA) of 20/20 or better", "description": "Percentage of patients with an uncorrected visual acuity (UCVA) of 20/20 or better", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS24", "title": "Refractive Surgery: Patients with a postoperative correction within + or - 0.5 Diopter (D) of the intended correction", "description": "Percentage of patients with an actual spherical equivalent within + or - 0.5 D of the intended correction or SE", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS27", "title": "Complications After Cataract Surgery", "description": "Percentage of patients aged 18 years and older with a diagnosis of cataract who had cataract surgery and had the following complications with 90 days after cataract surgery: prolonged inflammation, incision complications, iris complications, retinal detachment, cystoid macular edema, corneal complications.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS35", "title": "Improvement of Macular Edema in Patients with Uveitis", "description": "Percentage of patients with uveitis and macular edema with a reduction of 20% or greater in the central subfield thickness on OCT within 90 days after treatment.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS36", "title": "Visual Acuity Improvement Following Cataract Surgery Combined with a Trabeculectomy or an Aqueous Shunt Procedure", "description": "Percentage of patients who underwent cataract surgery combined with a trabeculectomy or an aqueous shunt procedure who had their visual acuity improve 2 or more Snellen lines from their preoperative visual acuity between 4 and 6 months postoperatively.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS37", "title": "Post-operative opioid management following oculoplastic surgery", "description": "Percentage of patients aged 18 years and older who underwent oculoplastic surgical procedures who were assessed for opioid use/requirements post-operatively, defined by either not receiving opioids post-operatively, receiving opioids for pain for 7 days or less post-operatively, or if expected to require opioids for more than 7 days after the surgical procedure, having an opioid use management plan documented.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS38", "title": "Endothelial Keratoplasty - Dislocation Requiring Surgical Intervention", "description": "Percentage of endothelial keratoplasty patients with a rebubbling or revision or repair procedure within 90 days after surgery", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS39", "title": "Intraocular Pressure Reduction Following Trabeculectomy or an Aqueous Shunt Procedure", "description": "Percentage of patients who underwent trabeculectomy or aqueous shunt procedure who had IOP reduced by 20% or more from their pretreatment between 3 and 4 months of treatment or a reduction in overall number of glaucoma medications.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS40", "title": "Regaining Vision After Cataract Surgery", "description": "Percentage of patients aged 18 years and older with a diagnosis of cataract who had cataract surgery and 20/20 best-corrected distance visual acuity or better OR an improvement in best-corrected distance visual acuity within 30 days following the cataract surgery. Simple average of performance rates reported.\nRate 1: Patients with no comorbidities or additional procedures on the same date as the cataract surgery and a 20/20 or better post-operative best corrected distance visual acuity\nAND\nRate 2: Patients with comorbidities with a pre-operative visual acuity of 20/200 or better and a 2 lines or better improvement in the post-operative best-corrected distance visual acuity from preoperative visual acuity\nAND\nRate 3: Patients with comorbidities with a pre-operative visual acuity of 20/400 or worse and a 1 line or better improvement in the post-operative best-corrected distance visual acuity from pre-operative visual acuity", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "simpleAverage", "strata": [ { "name": "nocomorbidities", "description": "Patients with no comorbidities or additional procedures on the same date as the cataract surgery and a 20/20 or better post-operative best corrected distance visual acuity" }, { "name": "200", "description": "Patients with comorbidities with a pre-operative visual acuity of 20/200 or better and a 2 lines or better improvement in the post-operative best-corrected distance visual acuity from preoperative visual acuity" }, { "name": "400", "description": "Patients with comorbidities with a pre-operative visual acuity of 20/400 or worse and a 1 line or better improvement in the post-operative best-corrected distance visual acuity from pre-operative visual acuity" } ], "submissionMethods": [ "registry" ] }, { "measureId": "IRIS41", "title": "Improved visual acuity after epiretinal membrane treatment within 120 days", "description": "Percentage of patients with a 20% improvement in visual acuity within 120 days following epiretinal membrane treatment", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS42", "title": "Return to the OR or endophthalmitis within 90 days after epiretinal membrane surgical treatment", "description": "Percentage of patients with an epiretinal membrane who have returned to the OR (including repair of retinal detachment) or had endophthalmitis within 90 days of surgical treatment of epiretinal membrane.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS43", "title": "Intraocular Pressure Reduction Following Laser Trabeculoplasty", "description": "Percentage of patients who underwent laser trabeculoplasty who had IOP reduced by 20% or more from their pretreatment IOP or had a reduction in overall number of glaucoma medications.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS44", "title": "Visual Field Progression in Glaucoma", "description": "Percentage of patients with a diagnosis of glaucoma with a mean deviation loss of 3dB or more from their baseline value.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS45", "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 a loss of less than 3 Snellen lines (which is equivalent to less than 0.3 logMAR) of visual acuity within the past 12 months. First performance rate used for reporting. 2 rates calculated, but only 1 submitted, with the other calculated for internal quality improvement", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS46", "title": "Evidence of anatomic closure of macular hole within 90 days after surgery as documented by OCT", "description": "Percentage of patients with a macular hole who have evidence of anatomic closure documented by OCT within 90 days after surgical treatment.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS47", "title": "Return to the OR or endophthalmitis within 90 days after macular hole surgery", "description": "Percentage of patients with a macular hole who returned to the OR (including repair of retinal detachment) or had endophthalmitis within 90 days after surgical treatment for macular hole.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS48", "title": "Adult Surgical Esotropia: Postoperative alignment", "description": "Percentage of adult esotropia patients receiving surgical treatment with a post treatment alignment of 12 prism diopters (PD) or less.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS49", "title": "Surgical Pediatric Esotropia: Postoperative alignment", "description": "Percentage of surgical esotropia pediatric patients with a postoperative alignment of 12 prism diopters (PD) or less without a reoperation.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS5", "title": "Surgery for Acquired Involutional Ptosis: Patients with an improvement of marginal reflex distance (MRD)", "description": "Percentage of surgical ptosis patients with an improvement of MRD within 90 days postoperatively.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS50", "title": "Amblyopia: Interocular visual acuity", "description": "Percentage of newly diagnosed amblyopic patients with one or more of the following:\nA. a corrected interocular (or if not reported, the uncorrected) visual acuity difference < 0.23 logMAR 3-12 months after first diagnosis of amblyopia\nOR\nB. an improvement in the corrected visual acuity of the amblyopic eye of 3 or more Snellen lines (> or = 0.30 logMAR) 3-12 months after first diagnosis of amblyopia \nOR\nC. a final visual acuity in the amblyopic eye equal to 20/30 or better (less than or equal to 0.18 logMar) 3-12 months after first diagnosis of amblyopia", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS51", "title": "Acute Anterior Uveitis: Post-treatment visual acuity", "description": "Percentage of acute anterior uveitis patients with a post-treatment best corrected visual acuity of 20/20 or better or patients whose visual acuity had returned to their baseline value prior to onset of uveitis.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IRIS6", "title": "Acquired Involutional Entropion: Normalized lid position after surgical repair", "description": "Percentage of surgical entropion patients with normalized lid position within 90 days postoperatively.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN24", "title": "Vestibular Rehabilitation for Unilateral or Bilateral Vestibular Hypofunction", "description": "Percentage of patients diagnosed with unilateral or bilateral vestibular hypofunction who were referred, prescribed, recommended for, or received vestibular rehabilitation.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry, American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO12", "title": "Tympanostomy Tubes: Topical Ear Drop Monotherapy Acute Otorrhea", "description": "Percentage of patients age 6 months to 12 years of age at the time of the visit with a current diagnosis of an uncomplicated acute tympanostomy tube otorrhea (TTO) who were prescribed or recommended to use topical antibiotic eardrops and NOT prescribed systemic (IV or PO) antibiotics for acute tympanostomy tube otorrhea.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO13", "title": "Bell's Palsy: Inappropriate Use of Magnetic Resonance Imaging or Computed Tomography Scan (Inverse Measure)", "description": "Percentage of patients age 16 years and older with a new onset diagnosis of Bell's palsy within the past 3 months who had a magnetic resonance imaging (MRI) or a computed tomography scan (CT) of the internal auditory canal, head, neck or brain ordered for the primary diagnosis of Bell's palsy.", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO16", "title": "Age-related Hearing Loss: Audiometric Evaluation", "description": "Percentage of patients age 60 years and older who failed a hearing screening and/or who report suspected hearing loss who received, were ordered, or were referred for comprehensive audiometric evaluation within 4 weeks the office visit.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO17", "title": "Age-related Hearing Loss: Advanced Diagnostic Imaging of Bilateral Presbycusis or Symmetric SNHL", "description": "Percentage of patients age 60 years and older with a diagnosis of bilateral presbycusis or symmetric sensorineural hearing loss who were NOT ordered magnetic resonance imaging (MRI) or a computed tomography scan (CT scan) of the brain, temporal bone or internal auditory canal for the primary indication of hearing loss.", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO20", "title": "Tympanostomy Tubes: Hearing Test", "description": "Percentage of patients age 6 months through 12 years with a diagnosis of OME who received tympanostomy tube insertion and received a hearing test within 6 months prior to tympanostomy tube insertion", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO21", "title": "Otitis Media with Effusion: Hearing Test for Chronic OME > 3 months", "description": "Percentage of patients age 6 months to 12 years of age at the time of the visit with a diagnosis of otitis media with effusion including chronic serous, mucoid, or nonsuppurative otitis media with effusion of >=3 months duration who had audiometry performed, ordered or who were referred for an audiometric evaluation.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO23", "title": "Allergic Rhinitis: Intranasal Corticosteroids or Oral Antihistamines", "description": "Percentage of patients with allergic rhinitis who are offered intranasal corticosteroids (INS) or non-sedating oral antihistamines", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO24", "title": "Allergic Rhinitis: Avoidance of Leukotriene Inhibitors", "description": "Percentage of patients with allergic rhinitis who do not receive leukotriene inhibitors", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO27", "title": "Tympanostomy Tubes: Resolution of Otitis Media with Effusion in Children", "description": "Percentage of patients aged 6 months to 12 years with a diagnosis of otitis media with effusion who are seen 2 to 8 weeks after tympanostomy tube surgery and otitis media with effusion is resolved.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO28", "title": "Tympanostomy Tubes: Resolution of Otitis Media with Effusion in Adults", "description": "Percentage of patients >12 years of age with a diagnosis of otitis media with effusion who are seen 2 to 8 weeks after tympanostomy tube surgery and otitis media with effusion is resolved.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO29", "title": "Quality of Life for Patients with Neurotology Disorders", "description": "Percentage of neurotology patients whose most recent Quality of Life scores were maintained or improved during the measurement period.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO30", "title": "Early Oral Cancer: Staging and Treatment", "description": "Percentage of patients with a diagnosis of oral cavity cancer seen in the practice setting who have a TNM cancer stage documented in the medical record within one month of the first office visit AND who receive treatment if identified with a primary tumor depth > 4 mm\nRate 1: Patients aged 18 and older diagnosed with early oral cavity cancer.\nRate 2: Patients 18 years or older diagnosed with clinical node negative (clinical state T1N0M0 or T2N0M0) oral cavity cancer with the depth of the primary tumor > 4mm documented in the medical record within one month of the first office visit", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "weightedAverage", "strata": [ { "name": "early", "description": "Patients aged 18 and older diagnosed with early oral cavity cancer." }, { "name": "node", "description": "Patients 18 years or older diagnosed with clinical node negative (clinical state T1N0M0 or T2N0M0) oral cavity cancer with the depth of the primary tumor > 4mm documented in the medical record within one month of the first office visit" } ], "submissionMethods": [ "registry" ] }, { "measureId": "AAO31", "title": "Otitis Media with Effusion (OME): Avoidance of Inappropriate Use of Medications", "description": "Percentage of patients age 2 months through 12 years with a diagnosis of otitis media with effusion who were not prescribed or recommended the use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO32", "title": "Standard BPPV Management", "description": "Percentage of BPPV patients who received vestibular testing, imaging, and antihistamine or benzodiazepine medications (Inverse Measure).", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO33", "title": "Age-related Hearing Loss: Shared Decision Making", "description": "Patients age 60 years and older with a diagnosis of bilateral presbycusis or symmetric sensorineural hearing loss or their caregiver(s) who report shared decision making with a healthcare provider regarding treatment options for their hearing loss using a standardized tool and a subsequent plan of care.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "patientEngagementExperience", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO34", "title": "Dysphonia: Postoperative Laryngeal Examination", "description": "Percentage of patients age 18 years and older who were diagnosed with new onset dysphonia within 2 months after a thyroidectomy who received or were referred for a laryngeal examination to examine vocal fold/cord mobility, and, if abnormal vocal fold mobility is identified, receive a plan of care for voice rehabilitation.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAO35", "title": "Benign Positional Paroxysmal Vertigo (BPPV): Dix-Hallpike and Canalith Repositioning", "description": "Percentage of patients with BPPV who had a Dix-Hallpike maneuver performed AND who had therapeutic canalith repositioning procedure (CRP) performed or who were referred for physical therapy or to a provider who can perform CRP if identified with posterior canal BPPV", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry, Axon Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASPS16", "title": "Airway Assessment for patients undergoing Rhinoplasty", "description": "Percentage of patients aged 15 years and older who had a rhinoplasty procedure for whom the nasal airway was assessed with physical examination via anterior rhinoscopy and documentation of status of the septum, turbinates, and valves.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ASPS TOPS-QCDR, American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASPS17", "title": "Patient Satisfaction with Rhinoplasty Procedure", "description": "Percentage of patients aged 15 years and older who had a rhinoplasty procedure who demonstrated improvement* in functional and/or aesthetic satisfaction using a validated patient satisfaction tool (such as SCHNOS, NOSE, SNOT, RHINO) within a year following their procedure. \n*pre-test and post-test scores must be documented in the patient record", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ASPS TOPS-QCDR, American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASPS18", "title": "Shared-decision making for post-operative management of discomfort following Rhinoplasty", "description": "Percentage of patients aged 15 years and older who had a rhinoplasty procedure who had documentation of a pre-operative shared-decision making strategy for multi-modal post-operative management of discomfort.\nDefinitions: Documentation of discussion of at least two mechanisms of pain management from the following terms or phrases (one term or phrase from each list) will meet the measure:\nNon-opioid analgesics: Non-narcotic/Non-opioid, Acetaminophen/Tylenol, Cox-II inhibitor (Celecoxib), Local/Marcaine/Block, Anxiolytic, Tramadol, NSAID/ibuprofen\n\nNon-systemic: Ice/Cooling, Elevation, Rest, Mindfulness, Meditation", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ASPS TOPS-QCDR, American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASPS19", "title": "Pre-surgical discussion of motivations and outcomes for patients undergoing Rhinoplasty", "description": "Percentage of patients aged 15 years and older who had a rhinoplasty procedure and with whom motivation for surgery and outcome expectations were discussed and for whom the following information was documented:\n1. Discussion of motivations and expectations*\n2. Surgical goals were realistic and exclusion criteria were reviewed\nDefinitions: *Documentation of any of words motivation, expectation, realistic, or unrealistic AND one of the following terms or phrases will meet the measure:\nIndependent /Preference/Desire/Look like/Appearance\nSize: Big(ger), small(er)\nShape: Straight, crooked, bent, hook, hump, bump, droop, flare, wide, thin, narrow, bulbous, pug, pointy, projection, rotation, flare, round, long(er), short(er)\nProportion/Balance: Tip, bridge, overly-prominent nostrils/nostril asymmetry, change of appearance with smiling (pulling or widening), general asymmetry\nExternal shaming/Ridicule/Bullying/Advice/Critical/Tease(ing)\nSelf-esteem/Self-conscious\nFacial Harmony/ gender characteristics/ ethnicity\nFunction: Breathe/Breathing, Repair injury, Snoring, Olfaction, Recurrent infection, Altered sensation, Voice change\nRealistic/Unrealistic", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ASPS TOPS-QCDR, American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACMT1", "title": "Screening for risk of opioid misuse/overuse", "description": "Percentage of patients aged 12 years or older who were screened for the potential risk of opioid misuse/overuse", "nqfId": null, "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Medical Toxicology (ACMT) ToxIC Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACMT2", "title": "Pregnancy test in women with a suspected toxicologic exposure", "description": "Percentage of women of childbearing age (12-60 years) who are seen by a medical toxicologist in the emergency department or inpatient setting with a suspected toxicologic exposure, who receive a pregnancy test prior to emergency department discharge or within 24 hours of hospital admission.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Medical Toxicology (ACMT) ToxIC Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACMT3", "title": "EKG assessment in acute overdoses", "description": "Percentage of drug overdose patients with EKG QRS and QTC duration assessment within 60 minutes of arrival to the emergency department.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Medical Toxicology (ACMT) ToxIC Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACMT4", "title": "Appropriate treatment for acetaminophen ingestions", "description": "% of patients of any age with an acetaminophen ingestion for which n-acetylcysteine (NAC) was initiated and discontinued appropriately", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Medical Toxicology (ACMT) ToxIC Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACMT5", "title": "Assessment of suspected ethylene glycol or methanol exposures", "description": "Percentage of patients of any age with suspected exposure to ethylene glycol or methanol for whom appropriate laboratory testing was available within 4 hours of hospital presentation.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Medical Toxicology (ACMT) ToxIC Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACMT6", "title": "Repeat assessment of salicylate concentrations in overdose patients", "description": "Percentage of patients of any age with suspected drug overdose with an initial plasma salicylate concentration >15 mg/dL who had a second plasma salicylate concentration sample collected within 4 hours following the time the initial sample was obtained", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Medical Toxicology (ACMT) ToxIC Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACPGR1", "title": "High Risk Pneumococcal Vaccination", "description": "The percentage of patients aged 19 through 64 with a high risk condition, who either received a pneumococcal vaccination OR who reported previous receipt of a pneumococcal vaccination.", "nqfId": null, "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Physicians Genesis Registry, Powered by Premier, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACPGR2", "title": "Tdap (Tetanus, Diphtheria, Acellular Pertussis) Vaccination", "description": "Percentage of patients aged 19 or older who received a primary vaccine series of tetanus/diphtheria/acellular pertussis (tdap) vaccine OR who reported previous receipt of Tdap booster vaccination.", "nqfId": null, "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Physicians Genesis Registry, Powered by Premier, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD1", "title": "CT Colonography True Positive Rate", "description": "Percentage of exams with a >=10mm polyp detected by CTC that was with confirmed by colonoscopy (True Positive Rate)", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD15", "title": "Report Turnaround Time: Radiography", "description": "Mean radiography report turnaround time (RTAT). (Does not include mammography.)\nThis measure has been harmonized with MSN QCDR.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD16", "title": "Report Turnaround Time: Ultrasound (Excluding Breast US)", "description": "Mean Ultrasound report turnaround time (RTAT)\nThis measure has been harmonized with MSN QCDR.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD17", "title": "Report Turnaround Time: MRI", "description": "Mean MRI report turnaround time (RTAT)\nThis measure has been harmonized with MSN QCDR.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD18", "title": "Report Turnaround Time: CT", "description": "Mean CT report turnaround time (RTAT)\nThis measure has been harmonized with MSN QCDR.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD19", "title": "Report Turnaround Time: PET", "description": "Mean PET report turnaround time (RTAT)\nThis measure has been harmonized with MSN QCDR.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD25", "title": "Report Turnaround Time: Mammography", "description": "Mean mammography report turnaround time (RTAT).\nThis measure has been harmonized with MSN QCDR.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD26", "title": "Appropriate venous access for hemodialysis", "description": "Percentage of patients undergoing tunneled (long-term) catheter access for hemodialysis via subclavian access as compared to internal jugular access", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD29", "title": "Rate of percutaneous nephrostomy tube replacement within 30 days secondary to dislodgement", "description": "Percentage of percutaneous nephrostomy tube replacement within 30 days following initial placement.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD30", "title": "Rate of Inadequate Percutaneous Image-Guided Biopsy", "description": "The percentage of percutaneous image-guided (US, CT, fluoro) biopsy procedures performed in which sampling was inadequate for diagnosis on the final pathology report.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD34", "title": "Multi-strata weighted average for 3 CT Exam Types: Overall Percent of CT exams for which Dose Length Product is at or below the size-specific diagnostic reference level (for CT Abdomen-pelvis with contrast/single phase scan, CT Chest without contrast/single phase scan and CT Head/Brain without contrast/single phase scan)", "description": "Weighted average of 3 former QCDR measures, ACRad 31, ACRad 32, Acrad 33.\nRate 1: CT Abdomen-pelvis with contrast/single phase scan, Rate 2: CT Chest without contrast/single phase scan and Rate 3: CT Head/Brain without contrast/single phase scan", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "weightedAverage", "strata": [ { "name": "abdomen", "description": "CT Abdomen-pelvis with contrast/single phase scan," }, { "name": "chest", "description": "CT Chest without contrast/single phase scan and" }, { "name": "head", "description": "CT Head/Brain without contrast/single phase scan" } ], "submissionMethods": [ "registry" ] }, { "measureId": "ACRAD35", "title": "Screening Mammography Early Cancer Detection Rate", "description": "Percentage of cancers detected at screening mammography that were detected when minimal or node negative", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American College of Radiology National Radiology Data Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA12", "title": "Benign Prostate Hyperplasia: IPSS improvement after diagnosis", "description": "Percentage of patients with NEW diagnosis of clinically significant BPH who had IPSS (international prostate symptoms score) or AUASS (American urological association symptom score) improvement by >=20%.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA14", "title": "Stones: Repeat Shock Wave Lithotripsy (SWL) within 6 months of treatment", "description": "Percentage of patients who underwent endoscopic procedures following SWL", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA15", "title": "Stones: Urinalysis documented 30 days before surgical stone procedures", "description": "Percentage of patients with a documented urinalysis 30 days before surgical stone procedures", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA16", "title": "Non-Muscle Invasive Bladder Cancer: Repeat Transurethral Resection of Bladder Tumor (TURBT) for T1 disease", "description": "Percentage of patients with T1 disease, that had a second TURBT within 6 weeks of the initial TURBT", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA17", "title": "Non-Muscle Invasive Bladder Cancer: Initiation of BCG within 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", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA18", "title": "Non-Muscle Invasive Bladder Cancer: Early surveillance cystoscopy within 4 months of initial diagnosis", "description": "Percentage of patients who receive surveillance cystoscopy within 4 months of TURBT for bladder cancer", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA19", "title": "Diagnosis of Type of Azoospermia and Diagnostic Testing for Obstructive Azoospermia", "description": "Percentage of patients who had minimum necessary concepts discussed as part of diagnosis of azoospermia alone, to determine possibility of obstructive versus non-obstructive azoospermia and underwent diagnostic testing for obstructive azoospermia", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA21", "title": "Appropriate Management of Obstructive Azoospermia", "description": "Percentage of obstructive azoospermia patients managed appropriately", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA22", "title": "Bone imaging and soft tissue imaging within 30 days (before or after) of diagnosis of metastatic CRPC", "description": "Percentage of patients who receive bone imaging and soft tissue imaging within 30 days (before or after) of diagnosis of metastatic CRPC", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA23", "title": "Blood work for patients receiving abiraterone", "description": "Percentage of patients receiving abiraterone who receive monthly blood work and serum transaminases (ALT and AST) and bilirubin levels prior to starting treatment and every two weeks for the first three months of treatment and monthly thereafter", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA24", "title": "Testosterone and PSA levels checked for CRPC patients", "description": "Percentage of patients on hormonal therapy who have their testosterone and PSA levels checked before starting treatment for CRPC", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA25", "title": "Use of Prednisone for CRPC patients on abiraterone", "description": "Percentage of patients who are receiving abiraterone who are also receiving prednisone", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA26", "title": "Benign Prostate Hyperplasia Care: Benign Prostate Hyperplasia", "description": "Percentage of patients with new diagnosis of BPH who had a creatinine lab order placed or had a CT abdomen, MRI abdomen, ultrasound abdomen ordered or performed.", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA27", "title": "Appropriate Testing for Vasectomy Patients", "description": "Percentage of patients where a Post Vasectomy Semen Analysis (PVSA) was ordered and confirmed sterility within 6 months of undergoing a vasectomy", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA29", "title": "Prostate Cancer: Patient Report of Urinary function after treatment", "description": "Percentage of patients who had a reported urinary function score at 12 months after treatment that is within 80% of the reported urinary function score at baseline (before treatment)", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA30", "title": "Prostate Cancer: Patient Report of Sexual function after treatment", "description": "Percentage of patients who had a reported sexual function score at 24 months after treatment that is within 60% of the reported sexual function score at baseline (before treatment)", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA31", "title": "Prostate Cancer: Documentation of PSA, Gleason score and clinical stage for risk stratification", "description": "Percentage of patients newly diagnosed with Prostate Cancer with documentation of PSA, Gleason score and clinical stage in the MD notes before treatment.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA32", "title": "Hypogonadism: Laboratory evaluation conducted within 6 months of starting testosterone replacement", "description": "Percentage of men age 18 years and older with testosterone deficiency who have a serum luteinizing hormone (LH) level, testosterone level, and hematocrit measured within 6 months of the initial testosterone level measurement", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA33", "title": "Intracavernosal Injection Therapy In-Office Test", "description": "Percentage of men who are prescribed intracavernosal injection therapy and received in-office testing", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQUA34", "title": "Genetic Testing and Patient Counseling of the Azoospermic Male", "description": "Percentage of patients with non-obstructive azoospermia due to primary testis failure who were offered genetic testing and patient counseling", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MUSIC10", "title": "Prostate Cancer: Confirmation Testing in low risk AS eligible patients", "description": "Percentage of low risk patients that are eligible for active surveillance who receive confirmation testing within 6 months of diagnosis", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC) QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MUSIC11", "title": "Prostate Cancer: Follow-Up Testing for patients on active surveillance for at least 30 months", "description": "Percentage of patients on active surveillance that have >= 2 tumor burden reassessments and 3 PSA tests in first 30 months since diagnosis", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC) QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MUSIC4", "title": "Prostate Cancer: Active Surveillance/Watchful Waiting for Low Risk Prostate Cancer Patients", "description": "Proportion of patients with low-risk prostate cancer receiving active surveillance or watchful waiting", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC) QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "QOPI21", "title": "Oncology: Treatment Summary Communication - Radiation Oncology", "description": "Percentage of patients, regardless of age, with a diagnosis of cancer who have undergone brachytherapy or external beam radiation therapy who have a treatment summary report in the chart that was communicated to the physician(s) providing continuing care and to the patient within two weeks of completing treatment", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "QOPI Reporting Registry (QCDR) Brought to you by ASCO and ASTRO", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "QOPI22", "title": "External Beam Radiotherapy for Bone Metastases", "description": "Percentage of patients, regardless of age, with a diagnosis of painful bone metastases and no history of previous radiation who receive external beam radiation therapy (EBRT) with an acceptable fractionation scheme as defined by the guideline.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "QOPI Reporting Registry (QCDR) Brought to you by ASCO and ASTRO", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI18", "title": "Coronary Artery Bypass Graft (CABG): Prolonged Intubation - Inverse Measure", "description": "Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI49", "title": "Adherence to Blood Conservation Guidelines for Cardiac Operations using Cardiopulmonary Bypass (CPB) - Composite", "description": "Percentage of patients, aged 18 years and older, who undergo a cardiac operation using cardiopulmonary bypass for whom selected blood conservation strategies were used.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AQI65", "title": "Avoidance of Cerebral Hyperthermia for Procedures Involving Cardiopulmonary Bypass", "description": "Percentage of patients, aged 18 years and older, undergoing a procedure using cardiopulmonary bypass who did not have a documented intraoperative pulmonary artery, oropharyngeal, or nasopharyngeal temperature >=37.0 degrees Celsius during the period of cardiopulmonary bypass", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "QUANTUM31", "title": "Central Line Ultrasound Guidance", "description": "Percentage of patients, regardless of age, in whom ultrasound guidance is used by the anesthesia clinician when placing a central line for those central lines that are placed in the internal jugular location.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MEDNAX QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "EPREOP29", "title": "Preoperative Assessment for Opioid Dependence Risk", "description": "Percentage of patients, aged 18 years and older, who undergo preoperative assessment of opioid dependence risk prior to elective surgery and care team is notified.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Registry (AQR QCDR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "EPREOP30", "title": "Ultrasound Guidance for Peripheral Nerve Block with Patient Experience", "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 and the patient is sent a survey within 30 days and the survey indicates experience with nerve block.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Registry (AQR QCDR)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CCOME1", "title": "Patient-Reported Pain and/or Function Improvement after Total Knee Arthroplasty", "description": "Percentage of patients aged 18 years or older who obtained at least a 10% improvement in knee pain and/or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and 9 to 15 months after undergoing primary total knee arthroplasty (TKA) surgery. PROMs include any validated measures of knee-related pain and/or function, such as KOOS-Pain, KOOS-ADL, KOOS-PS, and KOOS-JR.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Cleveland Clinic OME, QI FORCE", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AUGS1", "title": "Complete assessment and evaluation of patient's pelvic organ prolapse prior to surgical repair", "description": "Percentage of patients undergoing surgical repair of pelvic organ prolapse who have a documented, complete characterization of pelvic organ prolapse in each vaginal compartment using one of the accepted, objective measurement systems (POP_Q or Baden/Walker).", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AQUIRE", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AUGS10", "title": "Documentation of offering a preoperative pessary for Pelvic Organ Prolapse", "description": "The percentage of patients who have been offered a pessary for the treatment of pelvic organ prolapse prior to surgical intervention", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AQUIRE", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AUGS11", "title": "Documentation that a trial of conservative management was offered prior to use of procedure based therapy for urgency urinary incontinence", "description": "The percentage of patients offered conservative measures for the management of urgency urinary incontinence prior to use of procedure based therapy.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AQUIRE", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AUGS5", "title": "Performing vaginal apical suspension at the time of hysterectomy to address pelvic organ prolapse", "description": "Percentage of patients undergoing hysterectomy for the indication of pelvic organ prolapse in which a concomitant vaginal apical suspension (i.e. uterosacral, iliococygeus, sacrospinous or sacral colpopexy, or enterocele repair) is performed.", "nqfId": "2038", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AQUIRE", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AUGS6", "title": "Route of Hysterectomy", "description": "Percentage of patients who underwent vaginal hysterectomy.", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AQUIRE", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AUGS7", "title": "Documentation that conservative management was offered prior to fecal incontinence surgery or procedures", "description": "The percentage of patients offered non-surgical treatment options for fecal incontinence prior to surgery.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AQUIRE", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AUGS8", "title": "Documentation of weight loss counseling prior to surgery for stress urinary incontinence procedures for obese women", "description": "Percentage of obese patients having documented weight loss counseling prior to undergoing anti-urinary incontinence procedures.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "AQUIRE", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AUGS9", "title": "Over-utilization of synthetic mesh in the posterior compartment", "description": "Percentage of patients undergoing vaginal surgery for pelvic organ prolapse involving the posterior compartment where a synthetic mesh augment is utilized.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "AQUIRE", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASPS10", "title": "Patient Satisfaction with Information Provided during Breast Reconstruction", "description": "Percentage of patients aged 18 years and older who had breast reconstruction who reported a score of 65 or higher on the BREAST-Q Satisfaction with Information scale, within 120 days of the procedure. \n\nThis measure is reported as three rates stratified by procedure:\nRate 1: Implant Breast Reconstruction Procedures \nRate 2: Autologous Breast Reconstruction Procedures\nRate 3: All breast reconstruction Procedures", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ASPS TOPS-QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "implant", "description": "Implant Breast Reconstruction Procedures" }, { "name": "autologous", "description": "Autologous Breast Reconstruction Procedures" }, { "name": "overall", "description": "All breast reconstruction Procedures" } ], "submissionMethods": [ "registry" ] }, { "measureId": "ASPS11", "title": "Operative Time for Autologous Breast Reconstruction", "description": "Percentage of female patients aged 18 years and older who had unilateral breast reconstruction via autologous free tissue reconstruction with or without a tissue expander or implant whose operative time* did not exceed 8 hours.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ASPS TOPS-QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASPS12", "title": "Unplanned hospital admission after panniculectomy", "description": "Percentage of patients aged 18 years and older who undergo primary panniculectomy who have an unplanned hospital admission within 30 days of initial procedure", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ASPS TOPS-QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASPS20", "title": "Wound complications after primary panniculectomy in patients with BMI > or = to 30", "description": "Percentage of patients aged 18 years and older with a BMI > or = 30 who undergo primary panniculectomy who develop moderate or severe wound disruption OR clinically significant seroma requiring operative placement of a drain within 30 days of initial procedure.\n\nThis measure has 3 performance rates:\nRate 1: Moderate or Severe Wound Disruption\nRate 2: Clinically Significant Seroma Requiring Operative Placement of a Drain\nRate 3: Overall wound complications (wound disruption and seroma combined) (this is the rate that will be used for benchmarking)", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ASPS TOPS-QCDR", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "disruption", "description": "Moderate or Severe Wound Disruption" }, { "name": "drain", "description": "Clinically Significant Seroma Requiring Operative Placement of a Drain" }, { "name": "overall", "description": "Overall wound complications (wound disruption and seroma combined) (this is the rate that will be used for benchmarking)" } ], "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.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ASPS TOPS-QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASPS7", "title": "Rate of Blood Transfusion for Patients Undergoing Autologous Breast Reconstruction", "description": "Percentage of female patients aged 18 years and older who had breast reconstruction via autologous reconstruction (not including latissimus flap) with or without a tissue expander or implant who received blood or blood product transfusion during hospitalization.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ASPS TOPS-QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASPS8", "title": "Coordination of Care for Patients Undergoing Breast Reconstruction", "description": "Percentage of female patients aged 18 years and older with genetic susceptibility to malignant neoplasm of the breast, current diagnosis or history of breast cancer AND breast reconstruction with or without a tissue expander or implant who had documentation of coordinated care* prior to their procedure", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ASPS TOPS-QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASPS9", "title": "Length of Stay Following Autologous Breast Reconstruction", "description": "Percentage of female patients aged 18 years and older who had breast reconstruction via autologous reconstruction (not including latissimus flap) with or without a tissue expander or implant who were discharged from the hospital by the end of post-operative day 4", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ASPS TOPS-QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CDR1", "title": "Adequate Off-loading of Diabetic Foot Ulcer at each visit", "description": "Percentage of visits in which diabetic foot ulcers among patients aged 18 years and received adequate off-loading during a 12-month reporting period, stratified by location of the ulcer.\n\nThe location of the diabetic foot ulcer on the foot (e.g. heel/midfoot vs. toes) determines the type of off-loading device that is appropriate, the patient's risk of falling, the probability of successful off-loading and thus the likelihood of major amputation. The clinician needs to assess the most appropriate off-loading option based on many different factors. \n\nThere are three rates reported for this measure.\nThe three rates will be risk stratified into two buckets (location of wound and/or ulcer) which are the following:\nRate 1: Midfoot/heel\nRate 2: Toes\nRate 3: The average of the two risk stratified buckets which will be the performance rate in the XML submitted.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "midfoot/heel", "description": "Midfoot/heel" }, { "name": "toes", "description": "Toes" }, { "name": "overall", "description": "The average of the two risk stratified buckets which will be the performance rate in the XML submitted." } ], "submissionMethods": [ "registry" ] }, { "measureId": "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 diabetes (eg fasting blood sugar test, a hemoglobin A1C, or a 2 hour Glucose Tolerance Test) reviewed, requested or ordered when seen for an initial evaluation for distal symmetric polyneuropathy.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN10", "title": "Falls screening (aggregation of AAN disease specific falls measures)", "description": "Percentage of patients with Parkinson's disease, multiple sclerosis, distal symmetric polyneuropathy, ALS, epilepsy, dementia who were screened for falls at least annually and counseling provided on falls prevention for those with 2 or more falls or 1 fall with injury", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN11", "title": "Overuse of barbiturate and opioid containing medications for primary headache disorders", "description": "Percentage of patients age 12 years and older with a diagnosis of primary headache who were prescribed opioid or barbiturate containing medications assessed for medication overuse headache within the 12-month measurement period, and if identified as overusing opioid or barbiturate containing medication, treated or referred for treatment.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN12", "title": "Quality of Life Outcome for Patients with Epilepsy", "description": "Percentage of patients whose quality of life assessment results are maintained or improved during the measurement period.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN14", "title": "Current MS Disability Scale Score", "description": "Percentage of patients with MS who have a MS disability scale score* documented in the medical record in the past 12 months and had appropriate follow up", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN19", "title": "Botulinum Toxin Serotype A (BoNT-A) for spasticity or dystonia", "description": "Percentage of patients with spasticity or dystonia who were evaluated or referred or treated with BoNTA", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN20", "title": "Querying and follow-up for co-morbid conditions of tic disorder (TD) and Tourette syndrome (TS)", "description": "Percentage of patients who were queried for psychological and/or behavioral co-morbid conditions of tic disorder (TD) or Tourette syndrome (TS), and if present, treated or referred for treatment of co-morbid conditions", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN22", "title": "Global Health", "description": "Percentage of patients whose quality of life assessment results are maintained or improved during the measurement period.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN23", "title": "Avoidance of Dopamine-Blocking Medications in Patients with Parkinson's Disease", "description": "Percentage of patients with PD prescribed a contraindicated dopamine-blocking agent* (i.e., anti-psychotic, anti-nausea, anti-Gastroesophageal Reflux Disease (GERD)).", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN25", "title": "Pediatric Medication reconciliation", "description": "Percentage of pediatric patients who had a medication review at every encounter and a medication list present in the medical record.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN26", "title": "Activity counseling for back pain", "description": "Percentage of patients 18 to 65 years of age who were counseled to remain active and\nexercise or were referred to physical therapy", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN27", "title": "Falls plan of care", "description": "Percentage of patients that had a plan of care for falls documented", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN5", "title": "Medication Prescribed For Acute Migraine Attack", "description": "Percentage of patients age 12 years and older with a diagnosis of migraine who were prescribed a guideline recommended medication for acute migraine attacks within the 12 month measurement period.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN8", "title": "Exercise and Appropriate Physical Activity Counseling for Patients with MS", "description": "Percentage of patients with MS who are counseled* on the benefits of exercise and appropriate physical activity for patients with MS in the past 12 months.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN9", "title": "Querying About Symptoms of Autonomic Dysfunction for Patients with Parkinson's Disease", "description": "Percentage of all patients with a diagnosis of PD (or caregivers, as appropriate) who were queried about symptoms of autonomic dysfunction* in the past 12 months and if autonomic dysfunction identified had appropriate follow-up.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MICS4", "title": "Pain, Function and General Health Postoperative Improvement", "description": "Rate 1: Change in the calculated score of a validated general health, function, and/or pain score using a standard patient reported outcome survey from before to after surgery. \n \nRate 2: The overall percentage of patients that improve their general health, function, and/or pain scores beyond a minimum threshold for each postoperative interval.\n \nInstructions: Patients who undergo a surgical procedure are asked to complete an outcomes survey both preoperatively and following surgery. \n\nRationale: Understanding a patient's mental and general physical improvement, functional improvement, and improvement in pain levels as a result of surgery is an important aspect of clinical care. The general health scores, functional scores, and pain 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. Doctors have the option of collecting a postoperative outcomes survey at different intervals following surgery to account for different surgery types and physician follow-up patterns.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "CareSense", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "change", "description": "Change in the calculated score of a validated general health, function, and/or pain score using a standard patient reported outcome survey from before to after surgery." }, { "name": "overall", "description": "The overall percentage of patients that improve their general health, function, and/or pain scores beyond a minimum threshold for each postoperative interval." } ], "submissionMethods": [ "registry" ] }, { "measureId": "CCOME2", "title": "Patient-Reported Pain and/or Function Improvement after Total Hip Arthroplasty", "description": "Percentage of patients 18 years of age and older who obtained at least a 10% improvement in hip pain and/or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and 9 to 15 months after undergoing primary total hip arthroplasty (THA) surgery. PROMs include any validated measures of hip-related pain and/or function, such as HOOS-Pain, HOOS-ADL, HOOS-PS, and HOOS-JR.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Cleveland Clinic OME, QI FORCE", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CCOME3", "title": "Patient-Reported Pain and/or Function Improvement after Total Shoulder Arthroplasty", "description": "Percentage of patients 18 years of age and older who obtained at least a 10% improvement in shoulder pain and/or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and 9 to 15 months after undergoing primary total shoulder arthroplasty (TSA) surgery. PROMs include any validated measures of shoulder-related pain and/or function, such as PSS-Pain and PSS-Function.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Cleveland Clinic OME", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CCOME4", "title": "Patient-Reported Pain and/or Function Improvement after ACLR Surgery", "description": "Percentage of patients 13 years of age and older who obtained at least a 10% improvement in knee pain and/or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and 9 to 15 months after undergoing primary anterior cruciate ligament reconstruction (ALCR) surgery. PROMs include any validated measures of knee-related measures of pain and/or function, such as KOOS-Pain, KOOS-ADL, KOOS-PS, and KOOS-JR.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Cleveland Clinic OME", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CCOME5", "title": "Extent of Osteoarthritis Observed in Arthroscopic Partial Meniscectomy", "description": "Percentage of patients aged 45 and higher undergoing primary arthroscopic partial meniscectomy (APM) surgery who do not have grade IV chondromalacia in more than one compartment. On a per-surgeon level, the measure is expected to be 70% or higher; on a system level, the measure is expected to be 80% or higher.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Cleveland Clinic OME", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CCOME6", "title": "Patient-Reported Pain and/or Function Improvement after APM Surgery", "description": "Percentage of patients 13 years of age and older who obtained at least a 10% improvement in knee pain and/or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and 9 to 15 months after undergoing primary arthroscopic partial meniscectomy (APM) surgery. PROMs include any validated measures of knee-related measures of pain and/or function, such as KOOS-Pain, KOOS-ADL, KOOS-PS, and KOOS-JR.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Cleveland Clinic OME", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CLLC4", "title": "Foot Bone Infection Diagnosis Without MRI", "description": "Percentage of patients with a diagnosis of bone infection (osteomyelitis) in the foot who had an MRI of the foot.", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Clinigence VIP QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CLLC5", "title": "Monitoring for albuminuria in patients with CKD", "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", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Clinigence VIP QCDR", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CLLC6", "title": "Appropriate dosages of H2 blockers in patients with CrCl < 50 ml/min", "description": "The percentage of patients with GFR<50ml/min with current H-2 blocker prescription whose dosage is within the recommended daily limits", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Clinigence VIP QCDR", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CLLC7", "title": "Renal Dysfunction: New Oral Anticoagulants (NOACs) Management", "description": "The percentage of adult patients prescribed an ACEI, ARB, digoxin, diuretic, metformin, or NOACs who have had a serum creatinine measured in the past 12 months and who are on the appropriate dosage of NOACs based on renal function", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Clinigence VIP QCDR", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PPRNET13", "title": "Chronic Kidney Disease (CKD): eGFR Monitoring", "description": "The percentage of adult patients with Stage 3 or 4 CKD who have had a eGFR or serum creatinine in the past 6 months", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Clinigence VIP QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PPRNET14", "title": "Chronic Kidney Disease (CKD): Hemoglobin Monitoring", "description": "The percentage of adult patients with Stage 3B-Stage 5 CKD who have had a serum hemoglobin measured in the past 12 months", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Clinigence VIP QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PPRNET24", "title": "Appropriate Treatment for Adults with Upper Respiratory Infection", "description": "The percentage of adult patients seen within the past month and diagnosed with a common cold, pharyngitis or acute bronchitis who were not prescribed an antibiotic", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Clinigence VIP QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PPRNET31", "title": "Screening for Type 2 Diabetes", "description": "The percentage of patients 40 to 70 years of age who are overweight or obese and have been screened for type 2 diabetes in the past 3 years", "nqfId": null, "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Clinigence VIP QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PPRNET32", "title": "Screening for albuminuria in patients at risk for CKD (DM and/or HTN)", "description": "Test for albuminuria or urine protein in adults with Diabetes Mellitus or Hypertension and without CKD", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Clinigence VIP QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PPRNET33", "title": "Avoiding Use of CNS Depressants in Patients on Long-Term Opioids", "description": "The percentage of patients on long-term opioid prescriptions without a concurrent prescription for an CNS depressant", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Clinigence VIP QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PPRNET8", "title": "Antiplatelet Medication for High Risk Patients", "description": "The percentage of high risk patients who are prescribed an antiplatelet medication. High risk patients include those patients ages 50-69 years with >= 10% 10-year CVD risk", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Clinigence VIP QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SCG6", "title": "Outcome of High Risk Pain Medications Prescribed in Last 6 Months", "description": "Percentage of patients aged 18 years and older prescribed and actively taking one or more high risk medications in the last 6 months meeting the following criteria:\no Evaluation of polypharmacy AND \no Reduction to the high risk medication where clinically appropriate (e.g., change pain medication, 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"isRiskAdjusted": false, "primarySteward": "GIQuIC", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "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", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "GIQuIC, New Hampshire Colonoscopy Registry (NHCR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "GIQIC17", "title": "Appropriate follow-up interval of 5 years for colonoscopies with findings of sessile serrated polyps < 10 mm without dysplasia", "description": "Percentage of average-risk patients aged 50 years and older receiving a screening colonoscopy with biopsy or polypectomy and pathology findings of sessile serrated polyp(s) < 10 mm without dysplasia with a recommended follow-up interval of 5 years for repeat colonoscopy documented in their colonoscopy report", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "GIQuIC", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "GIQIC19", "title": "Appropriate indication for esophagogastroduodenoscopy (EGD)", "description": "Percentage of esophagogastroduodenoscopy (EGD) procedures performed for an indication that is included in a published standard list of appropriate indications and the indication is documented", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "GIQuIC", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "GIQIC21", "title": "Appropriate follow-up interval of not less than 5 years for colonoscopies with findings of 1-2 tubular adenomas < 10 mm OR of 10 years for colonoscopies with only hyperplastic polyp findings in rectum or sigmoid", "description": "Percentage of average-risk patients aged 50 years to 75 years receiving a screening colonoscopy with biopsy or polypectomy and pathology findings of 1 of 2 tubular adenomas < 10 mm with a recommended follow-up interval of not less than 5 years OR pathology findings of only hyperplastic polyp findings in rectum or sigmoid with a recommended follow-up interval of 10 years for repeat colonoscopy documented in their colonoscopy report\nRate 1: 1 to 2 tubular adenomas < 10 mm OR Rate 2: only hyperplastic polyp(s) in rectum or sigmoid", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "GIQuIC", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "weightedAverage", "strata": [ { "name": "tubular", "description": "1 to 2 tubular adenomas < 10 mm OR" }, { "name": "hyperplastic", "description": "only hyperplastic polyp(s) in rectum or sigmoid" } ], "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", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "New Hampshire Colonoscopy Registry (NHCR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "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.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Hawkins Foundation in Collaboration with SunCoast RHIO and CERortho", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "HF7", "title": "Surgical Repair for Rotator Cuff Tear: Change in a Validated Shoulder Patient Reported Outcome Measure Following Surgical Rotator Cuff Repair", "description": "The change in a validated shoulder measure score will be used as a performance measure for surgeons performing rotator cuff repair. Two measures will be created and reported by each surgeon. Surgeons will report the average shoulder measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted shoulder measure change score ratio by dividing the average patient shoulder measure change score by the average predicted patient shoulder measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level. Eligible validated shoulder patient reported outcome measures include: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Oxford Shoulder Score (OSS), Single Assessment Numeric Evaluation (SANE) [1] Defining the population: CPT-4 codes will be used to identify patients who received a rotator cuff repair surgery. Arthroscopic rotator cuff repair during the reporting period CPT-4 Codes: 29827, 29826 Surgeons who performed a minimum of 25 rotator cuff repair procedures a year will be eligible to submit this measure. Time period for data collection and reporting: This measure will be calculated using all patients who underwent rotator cuff repair during the observation period. Patients receiving rotator cuff repair during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the shoulder measure score are available. Measures: Two surgeon-level performance measures will be reported. The unadjusted measure will be the average 6 month shoulder measure change score across all rotator cuff repair patients treated by the surgeon. The adjusted measure will be the ratio of the average shoulder measure change score divided by the average predicted shoulder measure change score for all patients treated by the surgeon. Unadjusted measure: Average Shoulder Measure Change Score NUMERATOR: Sum of shoulder measure change scores from pre-surgery to 6 month post-surgery across all rotator cuff repair patients in the denominator. DENOMINATOR: The number of all patients who received rotator cuff repair during the observation window from the surgeon. Type of score: Validated shoulder measure change score average Risk adjusted measure: Shoulder Measure Change Score Ratio NUMERATOR: Average 6-month shoulder measure change score for all rotator cuff repair patients treated by surgeon. DENOMINATOR: Average predicted 6-month shoulder measure change score for all rotator cuff repair patients treated by surgeon. Risk adjustment methods and variables: The predicted 6-month shoulder measure change scores are estimated for each patient using the Center for Effectiveness Research In Orthopaedics' (CERortho) risk adjustment regression model that includes the following patient variables: age, gender, BMI, smoking status, comorbidities, worker's compensation status, prior shoulder surgery, tear size, tendon quality, the baseline shoulder measure score, and baseline measures of pain, shoulder function, and quality of life. [2, 3] Variables included in the current CERortho risk model are based on information in available databases. CERortho plans to constantly update these specified variables based on input from evaluated surgeons and specialty organizations. Appendix A contains the list of baseline concepts from the literature and American Academy of Orthopaedic Surgeons (AAOS) and peer-reviewed literature that are thought to affect outcomes of treatment and will be candidates for future inclusion in the model. [2, 3] Type of score: Ratio score; Interpretation of score: Surgeons with ratio scores equal to 1 have quality scores equal to the average surgeon given the characteristics of their patients. Surgeons with ratio scores greater than 1 had shoulder change scores higher than average. Surgeons with ratios scores less than 1 had shoulder change scores lower than average given the characteristics of their patients. Definitions: Patient's Shoulder Measure Score: A shoulder measure score is produced when the patient answers a validated shoulder assessment administered in the clinic or through an online portal. Patient's Shoulder Measure Change Score: A patient's change score is calculated by subtracting the patient's shoulder measure score at baseline from the patient's shoulder measure score at 6 month. Patient's Shoulder Measure Predicted Adjusted Change Score: Shoulder measure change scores for patients are risk adjusted using a regression model that includes the following independent variables age, gender, BMI, smoking status, comorbidities, worker's compensation status, prior shoulder surgery, tear size, tendon quality, the baseline shoulder measure score, and baseline measures of pain, shoulder function, and quality of life. [2, 3] The patient's predicted shoulder measure change score is the dependent variable. The regression model produces a risk-adjusted predicted shoulder measure change score for each patient. Risk-adjusted Shoulder Measure Change Score Ratio: The ratio between the actual change scores and the predicted change scores (after risk adjustment) is the ratio score. The risk-adjusted shoulder measure change score represents risk-adjusted change corrected for patient characteristics. A risk-adjusted ratio score of one or greater should be interpreted as change scores that were as good as or better than predicted given the risk-adjustment variables of the patient. Risk-adjusted ratio change scores less than one should be interpreted as shoulder measure change scores that were less than predicted given the risk-adjustment variables of the patient. The surgeon ratio scores can be used to make comparisons across surgeons. Steps: 1. Prior to rotator cuff repair surgery the patient completes a baseline validated shoulder measure assessment which generates the patient's shoulder measure score at baseline. 2. Six months after surgery, the patient completes the same validated shoulder measure assessment again, which generates the patient's shoulder measure score at 6 months. 3. The patient's raw, unadjusted shoulder measure change score is generated by subtracting the baseline score from the 6-month score. Unadjusted measure: 4. Patients' shoulder measure change scores are averaged by surgeon. Adjusted measure: 5. A risk-adjusted shoulder measure change score is predicted using the CERortho risk-adjustment regression model. 6. Patients' unadjusted and adjusted shoulder measure change scores are averaged by surgeon. 7. A risk-adjusted Shoulder Measure Change Score Ratio is generated for each surgeon. 8. The ratio scores for all surgeons in the database are ranked.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Hawkins Foundation in Collaboration with SunCoast RHIO and CERortho", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "HF8", "title": "Knee Arthroscopy for Meniscal Repair: Change in a Validated Knee Measure Following Knee Arthroscopy for Meniscal Repair", "description": "Percentage of patients in the denominator who obtained at least a 10% improvement in knee pain and/or function as measured by validated patient-reported outcome measures (PROMs) at 6 months post-op. \n \nEligible 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]", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "Hawkins Foundation in Collaboration with SunCoast RHIO and CERortho", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IROMS11", "title": "Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in knee rehabilitation of patients with knee injury measured via their validated Knee Outcome Survey (KOS) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.", "description": "The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the KOS change score for patients with knee injury patients treated during the observation period will be reported. \n\nAdditionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline KOS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). \n\nThese measures will serve as a PT/OT performance measure at the eligible PT/OT or PT/OT group level.\n\nSix measures will be reported, two overall performance measures and four stratified performance measures are to be included: \n\nRate 1: Overall proportion of patients not achieving an MCID in KOS change score will be reported. \nRate 2: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via KOS) proportion will reported. \n\nFor operative (surgical) patients:\nRate 3: The proportion of patients not achieving an MCID in KOS change score will be reported. \nRate 4: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via KOS) proportion will reported. \n\nFor non-operative (non-surgical) patients:\nRate 5: The proportion of patients not achieving an MCID in KOS change score will be reported. \nRate 6: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via KOS) proportion will reported.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Intermountain ROMS", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "notachieving", "description": "Overall proportion of patients not achieving an MCID in KOS change score will be reported." }, { "name": "overall", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via KOS) proportion will reported." }, { "name": "operativeMCID", "description": "The proportion of patients not achieving an MCID in KOS change score will be reported." }, { "name": "operativeRisk", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via KOS) proportion will reported." }, { "name": "nonOpMCID", "description": "The proportion of patients not achieving an MCID in KOS change score will be reported." }, { "name": "nonOpRisk", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via KOS) proportion will reported." } ], "submissionMethods": [ "registry" ] }, { "measureId": "IROMS13", "title": "Failure to Progress (FTP): Proportion of patients not achieving a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with hip, leg or ankle injuries using the validated Lower Extremity Function Scale (LEFS) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.", "description": "The proportion of patients failing to achieve an MCID of nine (9) points or more improvement in the LEFS change score for patients with hip, leg, or ankle injuries treated during the observation period will be reported. \n\nAdditionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline LEFS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). \n\nThese measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.\n\nSix measures will be reported, two overall performance measures and four stratified performance measures are to be included: \nRate 1: Overall proportion of patients achieving an MCID in LEFS change score will be reported. \nRate 2: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via LEFS) proportion will reported. \n\nFor operative (surgical) patients:\nRate 3: The proportion of patients not achieving an MCID in LEFS change score will be reported. \nRate 4: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via LEFS) proportion will reported. \n\nFor non-operative (non-surgical) patients:\nRate 5: The proportion of patients not achieving an MCID in LEFS change score will be reported. \nRate 6: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via LEFS) proportion will reported.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Intermountain ROMS", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "notachieving", "description": "Overall proportion of patients achieving an MCID in LEFS change score will be reported." }, { "name": "overall", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via LEFS) proportion will reported." }, { "name": "operativeMCID", "description": "The proportion of patients not achieving an MCID in LEFS change score will be reported." }, { "name": "operativeRisk", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via LEFS) proportion will reported." }, { "name": "nonOpMCID", "description": "The proportion of patients not achieving an MCID in LEFS change score will be reported." }, { "name": "nonOpRisk", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via LEFS) proportion will reported." } ], "submissionMethods": [ "registry" ] }, { "measureId": "IROMS15", "title": "Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with neck pain/injury measured via the validated Neck Disability Index (NDI).", "description": "The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the NDI change score for neck pain/injury patients treated during the observation period will be reported. \n\nAdditionally, a risk-adjusted NDI change proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline NDI score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).\n\nThese measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.\n\nSix measures will be reported, two overall performance measures and four stratified performance measures are to be included: \n\nRate 1: Overall proportion of patients achieving an MCID in NDI change score will be reported. \nRate 2: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported. \n\nFor operative (surgical) patients:\nRate 3: The proportion of patients not achieving an MCID in NDI change score will be reported. \nRate 4: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported. \n\nFor non-operative (non-surgical) patients:\nRate 5: The proportion of patients not achieving an MCID in NDI change score will be reported. \nRate 6: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Intermountain ROMS", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "notachieving", "description": "Overall proportion of patients achieving an MCID in NDI change score will be reported." }, { "name": "overall", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported." }, { "name": "operativeMCID", "description": "The proportion of patients not achieving an MCID in NDI change score will be reported." }, { "name": "operativeRisk", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported." }, { "name": "nonOpMCID", "description": "The proportion of patients not achieving an MCID in NDI change score will be reported." }, { "name": "nonOpRisk", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported." } ], "submissionMethods": [ "registry" ] }, { "measureId": "IROMS19", "title": "Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with arm, shoulder, and hand injury measured via the validated Disability of Arm Shoulder and Hand (DASH) score, Quick Disability of Arm Shoulder and Hand (QDASH) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.", "description": "The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the DASH change score or eight (8) points or more improvement in the QDASH change score for patients with arm, shoulder, and hand injury patients treated during the observation period will be reported. \n\nAdditionally, a risk-adjusted DASH change proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline MDQ score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).\n\nThese measures will serve as a physical and occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level. Six measures will be reported, two overall performance measures and four stratified performance measures are to be included: \nRate 1: Overall proportion of patients achieving an MCID in DASH change score will be reported. \nRate 2: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via DASH) proportion will reported. \n\nFor operative (surgical) patients: \nRate 3: The proportion of patients not achieving an MCID in DASH change score will be reported. \nRate 4: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via DASH) proportion will reported. \n\nFor non-operative (non-surgical) patients:\nRate 5: The proportion of patients not achieving an MCID in DASH change score will be reported.\nRate 6: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via DASH) proportion will reported.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Intermountain ROMS", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "notachieving", "description": "Overall proportion of patients achieving an MCID in DASH change score will be reported." }, { "name": "overall", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via DASH) proportion will reported." }, { "name": "operativeMCID", "description": "The proportion of patients not achieving an MCID in DASH change score will be reported." }, { "name": "operativeRisk", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via DASH) proportion will reported." }, { "name": "nonOpMCID", "description": "The proportion of patients not achieving an MCID in DASH change score will be reported." }, { "name": "nonOpRisk", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via DASH) proportion will reported." } ], "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", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "H-CPR (Hospitalist -Clinical Performance Registry)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HCPR16", "title": "Physician's Orders for Life-Sustaining Treatment (POLST) Form", "description": "Percentage of Patients Aged 65 Years and Older with Physician's Orders for Life-Sustaining Treatment (POLST) Forms Completed", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "H-CPR (Hospitalist -Clinical Performance Registry)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HCPR17", "title": "Pressure Ulcers - Risk Assessment and Plan of Care", "description": "Percentage of Adult Post-acute Facility Patients That Had a Risk Assessment for Pressure Ulcers and a Plan of Care for Pressure Ulcer Prevention/Treatment Completed", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "H-CPR (Hospitalist -Clinical Performance Registry)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HCPR18", "title": "Unintentional Weight Loss - Risk Assessment and Plan of Care", "description": "Percentage of Adult Post-acute Facility Patients that Had a Risk Assessment for Unintentional Weight Loss and a Plan of Care for Unintentional Weight Loss Documented by Provider", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "H-CPR (Hospitalist -Clinical Performance Registry)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HCPR19", "title": "30 Day All Cause Readmit 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\nRate 1: Overall Rate 2: Pneumonia Rate 3: CHF Rate 4: COPD.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "H-CPR (Hospitalist -Clinical Performance Registry)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "HCPR20", "title": "Clostridium Difficile - Risk Assessment and Plan of Care", "description": "Percentage of Adult Patients Who Had a Risk Assessment for C. difficile Infection and, If High-Risk, Had a Plan of Care for C. difficile Completed on the Day Of or Day After Hospital Admission", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "H-CPR (Hospitalist -Clinical Performance Registry)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HCPR21", "title": "Appropriate Use of Telemetry for Admission or Observation Placement", "description": "Percentage of Adult Patients with an Appropriate Diagnosis for Telemetry Admission or Observation Placement", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "H-CPR (Hospitalist -Clinical Performance Registry)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HCPR22", "title": "Critical Care Transfer of Care - Use of Verbal Checklist or Protocol", "description": "Percentage of Adult Patients Transferred from the Critical Care Service to a Non-critical Care Service Who Had Documented Use of a Verbal Protocol for the Transfer of Care Between the Transferring Clinician and the Accepting Clinician", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "H-CPR (Hospitalist -Clinical Performance Registry)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HCPR3", "title": "Mean Length of Stay for Inpatients - Pneumonia", "description": "Risk-Adjusted Mean LOS for All Inpatients Diagnosed with Pneumonia\n2 performance rates: Rate 1: Observed mean time/expected mean time Rate 2: Mean time.", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "H-CPR (Hospitalist -Clinical Performance Registry)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "HCPR4", "title": "Mean Length of Stay for Inpatients - CHF", "description": "Risk-Adjusted Mean LOS for All Inpatients Diagnosed with Congestive Heart Failure (CHF)\n2 performance rates: Rate 1: Observed mean time/expected mean time Rate 2: Mean time.", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "H-CPR (Hospitalist -Clinical Performance Registry)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "HCPR5", "title": "Mean Length of Stay for Inpatients - COPD", "description": "Risk-Adjusted Mean LOS for All Inpatients Diagnosed with Chronic Obstructive Pulmonary Disease (COPD)\n2 performance rates: Rate 1: Observed mean time/expected mean time Rate 2: Mean time.", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "H-CPR (Hospitalist -Clinical Performance Registry)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "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. \n\nThis measure is reported once per reporting period for each patient having one or more denominator qualifying visits.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "HealthAdvanta", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HADV2", "title": "Atrial Fibrillation Prevention and Treatment - Lifestyle and Disease Factor Assessment", "description": "Percentage of patients diagnosed with atrial fibrillation (afib) who are assessed for lifestyle and disease factors that contribute to uncontrolled atrial fibrillation at least once in the past 12 months. \n\nThis measure is reported once per reporting period for each patient having one or more denominator qualifying visits.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "HealthAdvanta", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HADV3", "title": "Emergency Department effective use of a HEART (History, ECG, Age, Risk factors, Troponin) Score for treatment of patients presenting with nontraumatic chest pain.", "description": "Number of Emergency Department visits for patients presenting with nontraumatic chest pain for whom a HEART score was calculated and Emergency Department discharge status was aligned with the HEART score risk unless prevailing factors exist.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "HealthAdvanta", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HMIQ1", "title": "Discharge Summary Completed within 1 Day of Discharge Date", "description": "Percentage of patients aged 18 years and older for which the eligible clinician completes a discharge summary within 1 day of the patient's discharge date.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Hospital Medicine Institute of Quality (HMIQ)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HMIQ2", "title": "Follow-Up Care Coordination Documented in Discharge Summary", "description": "Percentage of patients aged 18 years and older for which follow-up care coordination was documented in Hospital Discharge Summary", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Hospital Medicine Institute of Quality (HMIQ)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASNC19", "title": "Imaging Protocols for SPECT and PET MPI studies - Use of stress only protocol", "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) and Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies where the imaging protocol used was stress only performed on patients 18 years of age or older.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASNC23", "title": "SPECT-MPI study clinical utilization of Attenuation Correction image acquisition", "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies using Attenuation Correction performed on patients 18 years of age or older.", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASNC28", "title": "SPECT-MPI effective dose less than or equal to 9 millisieverts as per ASNC guideline recommendations", "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies where 9 or less millisieverts of radiation were administered per ASNC guideline recommendations on patients 18 years of age or older.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASNC29", "title": "SPECT and PET MPI study documentation of stress perfusion defects", "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) and Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies that were abnormal and contained perfusion defects documentation including location, severity, and size performed on patients 18 years of age or older.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ASNC30", "title": "Transthoracic Echo (TTE) studies meeting appropriate use criteria", "description": "Percentage of appropriate Transthoracic Echo (TTE) studies performed on patients 18 years of age or older.", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IGR1", "title": "Comprehensive TTE studies reporting a measured value of LVEF AND wall motion findings with LVEF < 50%", "description": "Percentage of comprehensive TTE studies reporting a measured value of LVEF and wall motion findings with LVEF < 50% on patients 18 years of age or older.", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IGR10", "title": "Transthoracic Echo (TTE) performance per ASE guidelines", "description": "Transthoracic Echo (TTE) performance per ASE guidelines on patients 18 years of age or older. This is a multi-strata measure consisting of the following:\nRate 1: Percentage of TTE studies reporting 100% obtainment of required views.\nRate 2: Percentage of TTE studies where the study quality was poor or technically difficult that utilized contrast.\nRate 3: Percentage of TTE studies reporting pulmonary artery pressures.\nRate 4: Percentage of TTE studies reporting of diastolic function.\nRate 5: Percentage of TTE studies reporting cardiac function using strain analysis in patients receiving chemotherapy.\nThe overall performance will be calculated using a weighted average.", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "weightedAverage", "strata": [ { "name": "obtainment", "description": "Percentage of TTE studies reporting 100% obtainment of required views." }, { "name": "contrast", "description": "Percentage of TTE studies where the study quality was poor or technically difficult that utilized contrast." }, { "name": "pulmonary", "description": "Percentage of TTE studies reporting pulmonary artery pressures." }, { "name": "diastolic", "description": "Percentage of TTE studies reporting of diastolic function." }, { "name": "cardiac", "description": "Percentage of TTE studies reporting cardiac function using strain analysis in patients receiving chemotherapy." } ], "submissionMethods": [ "registry" ] }, { "measureId": "IGR2", "title": "Parameters in dobutamine testing for low flow, low gradient aortic stenosis", "description": "Percentage of low flow, low gradient aortic stenosis studies with complete measurements during a dobutamine stress echocardiography on patients 18 years of age or older.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IGR3", "title": "Myocardial Perfusion Imaging (MPI) or Stress Echocardiography studies meeting appropriate use criteria", "description": "Percentage of stress echo, SPECT or PET MPI studies performed that are appropriate.", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IGR4", "title": "Myocardial Perfusion Imaging (MPI) studies or Stress Echocardiography imaging studies not Equivocal", "description": "Percentage of Single Photon Emission Computed Tomography (SPECT), Positron Emission Tomography (PET) or Stress Echocardiography imaging studies that are not equivocal.", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IGR5", "title": "Myocardial Perfusion Imaging (MPI) studies, Transthoracic Echo (TTE), or Stress Echocardiography imaging studies reporting Left Ventricular Ejection Fraction", "description": "Percentage of Single Photon Emission Computed Tomography (SPECT), Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI), transthoracic echocardiography, or stress echocardiography imaging studies where the Left Ventricle Ejection Fraction (LVEF) was calculated and included in the report performed on patients 18 years of age or older.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IGR6", "title": "SPECT-MPI or Stress Echocardiography imaging protocol selection for morbidly obese patients", "description": "Percentage of SPECT-MPI or Stress Echocardiography imaging studies where the Imaging Protocol was appropriate for morbidly obese patients.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "efficiency", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IGR7", "title": "SPECT-MPI or Stress Echocardiography imaging studies with adequate exercise testing performed", "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) or Stress Echocardiography exercise studies where the stress heart rate >= 85% of maximum heart rate and three or more minutes of exercise performed on patients 18 years of age or older.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IGR8", "title": "SPECT-MPI or Stress Echocardiography study utilization of exercise as a stressor", "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) or Stress Echocardiography studies using a Stress Test Type that includes exercise performed on patients 18 years of age or older.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IGR9", "title": "Stress echo performance for shortness of breath per ASE guidelines", "description": "Stress echo performance for shortness of breath per ASE guidelines on patients 18 years of age or older. This is a multi-strata measure consisting of the following: \nRate 1: Percentage of stress echo studies presenting with an indication of unexplained dyspnea that include an interpretation of LV diastolic function parameters with exercise.\nRate 2: Percentage of stress echo studies presenting with significant aortic and mitral valve disease that include reporting of value function and regurgitation with exercise. \nThe overall performance will be calculated using a weighted average.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "efficiency", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ImageGuide Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "weightedAverage", "strata": [ { "name": "dyspnea", "description": "Percentage of stress echo studies presenting with an indication of unexplained dyspnea that include an interpretation of LV diastolic function parameters with exercise." }, { "name": "aortic", "description": "Percentage of stress echo studies presenting with significant aortic and mitral valve disease that include reporting of value function and regurgitation with exercise." } ], "submissionMethods": [ "registry" ] }, { "measureId": "IROMS12", "title": "Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in revalidation patients with knee injury pain.", "description": "The proportion of patients failing to achieve MCID of two (2) points or more improvement in the NPRS change score for patients with knee injuries treated during the observation period will be reported. \n\nAdditionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline KOS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). \n\nThese measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.\n\nSix measures will be reported, two overall performance measures and four stratified performance measures are to be included: \n\nRate 1: Overall proportion of patients achieving an MCID in NDI change score will be reported. \nRate 2: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported. \n\nFor operative (surgical) patients:\nRate 3: The proportion of patients not achieving an MCID in NDI change score will be reported. \nRate 4: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported. \n\nFor non-operative (non-surgical) patients:\nRate 5: The proportion of patients not achieving an MCID in NDI change score will be reported. \nRate 6: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Intermountain ROMS", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "notachieving", "description": "Overall proportion of patients achieving an MCID in NDI change score will be reported." }, { "name": "overall", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported." }, { "name": "operativeMCID", "description": "The proportion of patients not achieving an MCID in NDI change score will be reported." }, { "name": "operativeRisk", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported." }, { "name": "nonOpMCID", "description": "The proportion of patients not achieving an MCID in NDI change score will be reported." }, { "name": "nonOpRisk", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported." } ], "submissionMethods": [ "registry" ] }, { "measureId": "IROMS14", "title": "Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with hip, leg or ankle (lower extremity except knee) injury.", "description": "The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with hip, leg, or ankle injuries treated during the observation period will be reported. \n\nAdditionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: LEFS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). \n\nThese measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.\n\nSix measures will be reported, two overall performance measures and four stratified performance measures are to be included: \n\nRate 1: Overall proportion of patients achieving an MCID in NDI change score will be reported. \nRate 2: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported. \n\nFor operative (surgical) patients:\nRate 3: The proportion of patients not achieving an MCID in NDI change score will be reported. \nRate 4: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported. \n\nFor non-operative (non-surgical) patients:\nRate 5: The proportion of patients not achieving an MCID in NDI change score will be reported. \nRate 6: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Intermountain ROMS", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "notachieving", "description": "Overall proportion of patients achieving an MCID in NDI change score will be reported." }, { "name": "overall", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported." }, { "name": "operativeMCID", "description": "The proportion of patients not achieving an MCID in NDI change score will be reported." }, { "name": "operativeRisk", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported." }, { "name": "nonOpMCID", "description": "The proportion of patients not achieving an MCID in NDI change score will be reported." }, { "name": "nonOpRisk", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported." } ], "submissionMethods": [ "registry" ] }, { "measureId": "IROMS16", "title": "Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with neck pain/injury.", "description": "The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with neck pain/injury treated during the observation period will be reported. \n\nAdditionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline NDI score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). \n\nThese measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.\n\nSix measures will be reported, two overall performance measures and four stratified performance measures are to be included: \n\nRate 1: Overall proportion of patients achieving an MCID in NDI change score will be reported. \nRate 2: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported. \n\nFor operative (surgical) patients:\nRate 3: The proportion of patients not achieving an MCID in NDI change score will be reported. \nRate 4: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported. \n\nFor non-operative (non-surgical) patients:\nRate 5: The proportion of patients not achieving an MCID in NDI change score will be reported. \nRate 6: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Intermountain ROMS", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "notachieving", "description": "Overall proportion of patients achieving an MCID in NDI change score will be reported." }, { "name": "overall", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported." }, { "name": "operativeMCID", "description": "The proportion of patients not achieving an MCID in NDI change score will be reported." }, { "name": "operativeRisk", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported." }, { "name": "nonOpMCID", "description": "The proportion of patients not achieving an MCID in NDI change score will be reported." }, { "name": "nonOpRisk", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported." } ], "submissionMethods": [ "registry" ] }, { "measureId": "IROMS17", "title": "Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation patients with low back pain measured via the validated Modified Low Back Pain Disability Questionnaire (MDQ) score.", "description": "The proportion of patients failing to achieve an MCID of six (6) points or more improvement in the MDQ change score for patients with low back pain treated during the observation period will be reported. \n\nAdditionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline MDQ score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). \n\nThese measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.\n\nSix measures will be reported, two overall performance measures and four stratified performance measures are to be included: \n\nRate 1: Overall proportion of patients not achieving an MCID in MDQ change score will be reported. \nRate 2: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via MDQ) proportion will reported. \n\nFor operative (surgical) patients:\nRate 3: The proportion of patients not achieving an MCID in MDQ change score will be reported. \nRate 4: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via MDQ) proportion will reported. \n\nFor non-operative (non-surgical) patients:\nRate 5: The proportion of patients not achieving an MCID in MDQ change score will be reported. \nRate 6: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via MDQ) proportion will reported.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Intermountain ROMS", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "notachieving", "description": "Overall proportion of patients not achieving an MCID in MDQ change score will be reported." }, { "name": "overall", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via MDQ) proportion will reported." }, { "name": "operativeMCID", "description": "The proportion of patients not achieving an MCID in MDQ change score will be reported." }, { "name": "operativeRisk", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via MDQ) proportion will reported." }, { "name": "nonOpMCID", "description": "The proportion of patients not achieving an MCID in MDQ change score will be reported." }, { "name": "nonOpRisk", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via MDQ) proportion will reported." } ], "submissionMethods": [ "registry" ] }, { "measureId": "IROMS18", "title": "Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in revalidation patients with low back pain.", "description": "The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with low back pain treated during the observation period will be reported. \n\nAdditionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline MDQ score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). \n\nThese measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.\n\nSix measures will be reported, two overall performance measures and four stratified performance measures are to be included: \n\nRate 1: Overall proportion of patients achieving an MCID in NDI change score will be reported. \nRate 2: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported. \n\nFor operative (surgical) patients:\nRate 3: The proportion of patients not achieving an MCID in NDI change score will be reported. \nRate 4: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported. \n\nFor non-operative (non-surgical) patients:\nRate 5: The proportion of patients not achieving an MCID in NDI change score will be reported. \nRate 6: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Intermountain ROMS", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "notachieving", "description": "Overall proportion of patients achieving an MCID in NDI change score will be reported." }, { "name": "overall", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported." }, { "name": "operativeMCID", "description": "The proportion of patients not achieving an MCID in NDI change score will be reported." }, { "name": "operativeRisk", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported." }, { "name": "nonOpMCID", "description": "The proportion of patients not achieving an MCID in NDI change score will be reported." }, { "name": "nonOpRisk", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported." } ], "submissionMethods": [ "registry" ] }, { "measureId": "IROMS20", "title": "Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with arm, shoulder, or hand injury.", "description": "The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with arm, shoulder, or hand injury treated during the observation period will be reported. \n\nAdditionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline DASH score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). \n\nThese measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.\n\nSix measures will be reported, two overall performance measures and four stratified performance measures are to be included: \n\nRate 1: Overall proportion of patients achieving an MCID in NDI change score will be reported. \nRate 2: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported. \n\nFor operative (surgical) patients:\nRate 3: The proportion of patients not achieving an MCID in NDI change score will be reported. \nRate 4: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported. \n\nFor non-operative (non-surgical) patients:\nRate 5: The proportion of patients not achieving an MCID in NDI change score will be reported. \nRate 6: A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Intermountain ROMS", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "notachieving", "description": "Overall proportion of patients achieving an MCID in NDI change score will be reported." }, { "name": "overall", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported." }, { "name": "operativeMCID", "description": "The proportion of patients not achieving an MCID in NDI change score will be reported." }, { "name": "operativeRisk", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported." }, { "name": "nonOpMCID", "description": "The proportion of patients not achieving an MCID in NDI change score will be reported." }, { "name": "nonOpRisk", "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported." } ], "submissionMethods": [ "registry" ] }, { "measureId": "K2MISSG1", "title": "Minimum Clinically Important Difference (MCID) of Patient-Reported Outcome Measurement Information System Computer Adapted Testing Physical Function Domain (PROMIS CAT PF) in Spine Surgery Patients", "description": "Compares pre-operative to post-operative (minimum 6-month) score utilizing PROMIS CAT PF outcomes measure and is positive for patients with a minimum difference in scores of 3.5.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "International Spine Study Group in Collaboration with K2M", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IQSS1", "title": "Hypogonadism: Serum T, CBC, PSA, IPSS within 6 months of Rx", "description": "Percentage of patients with a new diagnosis of hypogonadism receiving androgen replacement therapy who have serum T, CBC, PSA, and IPSS documented within 6 months of first treatment", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "IntrinsiQ Specialty Solutions", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IQSS2", "title": "Prostate Cancer: Newly diagnosed with documented T stage, PSA score, and Gleason score", "description": "Percentage of newly diagnosed prostate cancer patients who prior to treatment have a documented evaluation of primary tumor (T) stage, PSA score, and Gleason score", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "IntrinsiQ Specialty Solutions", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IQSS3", "title": "Prostate Cancer: Treatment Options Counseling", "description": "Newly diagnosed prostate cancer patients receiving definitive local treatment (surgery, radiation, cryotherapy) with documented counseling of all treatment options (active surveillance, surgery, radiation)", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "IntrinsiQ Specialty Solutions", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "IQSS4", "title": "BPH: Anticholinergics", "description": "Percentage of newly diagnosed BPH patients treated with anticholinergics where PVR is performed", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "IntrinsiQ Specialty Solutions", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MBHR1", "title": "Anxiety Utilization of the GAD-7 Tool", "description": "The percentage of adult patients (18 years and older) with an anxiety disorder diagnosis (generalized anxiety disorder, social anxiety disorder, post-traumatic stress disorder, or panic disorder) who have completed GAD-7 tool during measurement period", "nqfId": "n/a", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MBHR Mental and Behavioral Health Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MBHR2", "title": "Anxiety Response at 6-months", "description": "The percentage of adult patients (18 years of age or older) with an anxiety disorder (generalized anxiety disorder, social anxiety disorder, post-traumatic stress disorder, or panic disorder) who demonstrated a response to treatment at six months (+/- 60 days) after an index visit", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "MBHR Mental and Behavioral Health Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MBHR3", "title": "Pain Interference Response utilizing PROMIS", "description": "The percentage of adult patients (18 years of age or older) who report pain issues and demonstrated a response to treatment at one month from the index score", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MBHR Mental and Behavioral Health Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MBHR4", "title": "Social Role Functioning Outcome utilizing PROMIS", "description": "The percentage of adult patients (18 years of age or older) with a mood or anxiety disorder who report concerns related to their psychosocial function and demonstrated a response to treatment two months (+/- 30 days) after the index visit", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MBHR Mental and Behavioral Health Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MBHR5", "title": "Screening and monitoring for psychosocial problems among children and youth", "description": "Percentage of children from 3.00 to 17.99 years of age who are administered a parent-report, standardized and validated screening tool to assess broad-band psychosocial problems during an intake visit AND who demonstrated a reliable change in parent-reported problem behaviors 2 to 6 months after initial positive screen for externalizing and internalizing behavior problems.\n\nRate 1:\nPatients who were administered a psychiatric or behavioral health intake visit to assess broad-band psychosocial problems.\nRate 2:\ni. Patients who were administered a psychiatric or behavioral health intake visit with a positive PSC-ES screening who demonstrated a reliable improvement of 2 or more points on parent-report version of the PSC-ES assessment taken 2 to 6 months later. \nii. Patients who were administered a psychiatric or behavioral health intake visit with a positive PSC-IS screening who demonstrated a reliable improvement of 2 or more points on parent-report version of the PSC-IS assessment taken 2 to 6 months later", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MBHR Mental and Behavioral Health Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "broadband", "description": "Patients who were administered a psychiatric or behavioral health intake visit to assess broad-band psychosocial problems." }, { "name": "overall", "description": "i. Patients who were administered a psychiatric or behavioral health intake visit with a positive PSC-ES screening who demonstrated a reliable improvement of 2 or more points on parent-report version of the PSC-ES assessment taken 2 to 6 months later." } ], "submissionMethods": [ "registry" ] }, { "measureId": "MBHR6", "title": "Sleep Quality Screening and Sleep Response at 3-months", "description": "Percentage of patients 18 years and older who reported sleep quality concerns (e.g., insomnia) with documentation of a standardized tool AND demonstrated a response to treatment at three months (+/- 60 days) after index visit\n\nRate 1:\nPatients who reported sleep concerns (e.g., insomnia, hypersomnia), with a documented standardized tool to assess sleep quality and a documented care plan (e.g., Pittsburg Sleep Quality Index (PSQI), and the Insomnia Severity Index (ISI).\nRate 2:\nPatients with an Insomnia Severity Index (ISI) that is reduced by 25% or greater from the index Insomnia Severity Index (ISI) score, three months (+/- 60 days) after index date.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MBHR Mental and Behavioral Health Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "reported", "description": "Patients who reported sleep concerns (e.g., insomnia, hypersomnia), with a documented standardized tool to assess sleep quality and a documented care plan (e.g., Pittsburg Sleep Quality Index (PSQI), and the Insomnia Severity Index (ISI)." }, { "name": "overall", "description": "Patients with an Insomnia Severity Index (ISI) that is reduced by 25% or greater from the index Insomnia Severity Index (ISI) score, three months (+/- 60 days) after index date." } ], "submissionMethods": [ "registry" ] }, { "measureId": "MBSAQIP10", "title": "Risk standardized rate of patients who experienced a postoperative escalation in care event following a primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation", "description": "Primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy patients who experienced a postoperative escalation in care event\n\nOverall risk standardized escalation in care rate. This risk standardized rate is constructed as a composite so that the eligible patient must have none of the 4 escalation in care events to be considered \"Performance Not Met\" (inverse)\n(1) Readmission within 30 days of surgery \n(2) Reoperation within 30 days of surgery \n(3) Intervention within 30 days of surgery \n(4) Admission to ICU within 30 days of surgery", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "MBSAQIP QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MBSAQIP11", "title": "Risk standardized rate of patients who experienced a pulmonary complication following a primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy", "description": "Primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy patients who experienced a pulmonary complication\n\nOverall risk standardized pulmonary complication rate. This risk standardized rate is constructed as a composite so that the eligible patient must have none of the 4 pulmonary complications to be considered \"Performance Not Met\" (inverse)\n(1) Pneumonia within 30 days of surgery \n(2) Unplanned Intubation within 30 days of surgery\n(3) Pulmonary Embolism within 30 days of surgery\n(4) On Ventilator > 48 Hours within 30 days of surgery", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "MBSAQIP QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MBSAQIP8", "title": "Risk standardized rate of patients who experienced an extended length of stay (> 3 days) following a primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation", "description": "Primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy patients who experienced an extended length of stay (> 3 days)", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "MBSAQIP QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MEDNAX52", "title": "Use of a \"PEG Test\" to Manage Patients Receiving Opioids", "description": "Percentage of patients in an outpatient setting, aged 18 and older, in whom a stable dose of opioids are prescribed for greater than 6 weeks for pain control, and the results of a \"PEG Test\" are correctly interpreted and applied to the management of their opioid prescriptions.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MEDNAX QCDR", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MEDNAX53", "title": "Use of Capnography for non-Operating Room anesthesia", "description": "Percentage of patients receiving anesthesia in a non-operating room setting who have end-tidal carbon dioxide (ETCO2) monitored using capnography.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MEDNAX QCDR", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MEDNAX54", "title": "Labor Epidural Failure when Converting from Labor Analgesia to Cesarean Section Anesthesia", "description": "The percentage of patients who have pre-existing labor epidurals who require either supplemental sedation, spinal or general anesthesia for cesarean section.", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "MEDNAX QCDR", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MEDNAX55", "title": "Use of ASPECTS (Alberta Stroke Program Early CT Score) for non-contrast CT Head performed for suspected acute stroke.", "description": "Percentage non-contrast CT Head performed for suspected acute stroke whose final reports include an ASPECTS value.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MEDNAX QCDR", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MEX1", "title": "Heel Pain Treatment Outcomes for Adults", "description": "DESCRIPTION: \nPercentage of patients aged 18 years and older with a diagnosis of heel pain who had two or more encounters in the past year.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MedXpress Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MEX14", "title": "Foot Ulcer Prevention", "description": "Foot Ulceration in a diabetic is a major cause of morbidity for this patient population. Prevention of these ulcers is an important goal and outcome", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "intermediateOutcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MedXpress Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MEX2", "title": "Heel Pain Treatment Outcomes for Pediatric Patients", "description": "Percentage of patients aged 6 to 18 years with a diagnosis of heel pain who experience a decrease in heel pain.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MedXpress Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MEX3", "title": "Identification of Flat Foot in Pediatric Patients", "description": "Percentage of patients aged 6 - 18 years with a diagnosis of flat foot who had an encounter and treatment for flexible flat foot in the past year.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MedXpress Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MEX4", "title": "Bunion Outcome - Adult and Adolescent", "description": "Percentage of patients with a who have a hallux valgus (bunion) deformity causing pain", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MedXpress Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MEX5", "title": "Hammer Toe Outcome", "description": "Percentage of patients who have a painful hammer toe, claw toe, mallet toe or other lesser toe deformity causing disability", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MedXpress Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MUSIC12", "title": "Kidney Stones: ED visit within 30 days of ureteroscopy", "description": "Percentage of patients who underwent ureteroscopy and experienced an unplanned ED visit within 30 days of the procedure", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC) QCDR", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MUSIC13", "title": "Kidney Stones: Antibiotics should not be provided at the time of SWL", "description": "Percentage of patients who received antibiotics at the time of shockwave lithotripsy", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC) QCDR", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MUSIC14", "title": "Kidney Stones: Alphablockers at discharge for patients undergoing kidney stone surgery, Ureteroscopy or Shockwave Lithotripsy", "description": "Percentage of patients who underwent ureteroscopy or shockwave lithotripsy and received alphablockers at discharge", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC) QCDR", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MUSIC15", "title": "Kidney Stones: SWL in patients with total renal stone burden > 2 cm or > 1 cm lower pole stones", "description": "Percentage of patients who underwent shockwave lithotripsy with a total stone burden > 2 cm or > 1 cm lower pole stones", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC) QCDR", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MUSIC16", "title": "Kidney Stones: Opioid utilization after ureteroscopy", "description": "Percentage of patients who underwent ureteroscopy and are discharged on NSAIDS, Acetaminophen, or \"Other\" and who were not prescribed opioids for pain control", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC) QCDR", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MUSIC3", "title": "Prostate Cancer: Avoidance of Overuse of CT Scan for Staging Low Risk Prostate Cancer Patients", "description": "Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a CT scan performed at any time since diagnosis of prostate cancer", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC) QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MUSIC5", "title": "Prostate Cancer: Radical Prostatectomy Cases LOS", "description": "Percentage of radical prostatectomy cases with a length of stay > 2 days", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC) QCDR", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "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", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MiraMed", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MIRAMED19", "title": "Onset atrial fibrillation or dysrhythmia requiring unanticipated therapy", "description": "Percentage of patients, 18 or older, who exhibit sudden onset of atrial fibrillation or dysrhythmia requiring intervention immediately during an otherwise unrelated event.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "MiraMed", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MIRAMED20", "title": "Perioperative cognitive function test in elderly", "description": "Percentage of patients, aged 65 or older, who are receive a cognitive function test prior to the scheduled procedure.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MiraMed", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MIRAMED21", "title": "Propofol Management of Obese Patients", "description": "The percentage of obese patients who experience sedation-related complications undergoing endoscopic procedures using propofol-mediated sedation.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "MiraMed", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MIRAMED22", "title": "New acute respiratory failure", "description": "Percentage of patients, aged 18 or older, who experience an acute respiratory failure of any cause after emergence from general anesthesia and prior to anesthesia end time requiring either physical or pharmacological intervention.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "MiraMed", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACMS2", "title": "Closing the Mohs Surgery Referral Loop: Transmission of Surgical Report", "description": "Percentage of Mohs micrographic surgery cases, regardless of age, for which a report is sent from the treating provider to the referring provider within 30 days.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MohsAIQ", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACMS3", "title": "Antibiotic Prophylaxis for High Risk Cardiac / Orthopedic Cases prior to Mohs micrographic surgery - Prevention of Overuse", "description": "Percentage of cases of Mohs surgery in which preoperative prophylactic antibiotics were provided for which the patient had cardiac / orthopedic prophylaxis indications for preoperative antibiotics.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MohsAIQ", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACMS4", "title": "Surgical Site Infection Rate - Mohs Micrographic Surgery", "description": "Percentage of cases of Mohs surgery that develop a surgical site infection. This measure is to be reported each time a procedure for a Mohs surgery is performed whether or not a surgical site infection develops during the performance period.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "MohsAIQ", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MUSE1", "title": "CollaboRATE Shared Decision Making Score", "description": "CollaboRATE is a patient-reported measure of shared decision making. CollaboRATE provides a performance score representing the percentage of respondents who experience a high level of shared decision making. \nThe four items include: \n1) How much effort was made to help you understand your health issues? \n2) How much effort was made to listen to the things that matter most to you about your health issues? \n3) How much effort was made to include what matters most to you in choosing what to do next? 4) How much effort was made to explain whether treatment options are effective or not?\nEach item response is given on a 10-point scale, from 0 (No effort was made) to 9 (Every effort was made). The CollaboRATE Shared Decision Making Score represents the proportion of top box scores, i.e. the proportion of all responses with scores of 9 for each of the four collaboRATE items. Patient must answer all 4 questions with a \"top box\" score in order to be numerator compliant. If a patient does not answer one of the four questions, this would not meet the intent of the measure. CollaboRATE was developed to be generic and was designed so that it could apply to all clinical encounters, irrespective of medical condition or patient group.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "patientEngagementExperience", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MUSE Collaborative", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NHBPC10", "title": "Telephone Contact, Virtual, or In-person Visit Within 48 Hours of Hospital Discharge of Home-Based Primary Care and Palliative Care Patients", "description": "Percentage of actively enrolled home-based primary care and palliative care patients who had a telephone contact, virtual, or in-person visit within 48 hours of hospital discharge.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "patientEngagementExperience", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Home-Based Primary Care & Palliative Care Registry in Collaboration with the American Academy of Home Care Medicine, Powered by Premier", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NHBPC14", "title": "Cognitive Assessment and Plan of Care for Home-Based Primary Care and Palliative Care Patients", "description": "Percentage of actively enrolled home-based primary care and palliative care patients whose cognitive status was assessed at enrollment and annually and for whom a plan of care was described for those with cognitive impairment.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Home-Based Primary Care & Palliative Care Registry in Collaboration with the American Academy of Home Care Medicine, Powered by Premier", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NHBPC15", "title": "Functional Assessment (Basic and Instrumental Activities of Daily Living [ADL]) for Home-Based Primary Care and Palliative Care Patients", "description": "Percentage of actively enrolled home-based primary care and palliative care patients who are assessed for impairment of basic and instrumental activities of daily living (ADLs) at enrollment and annually.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Home-Based Primary Care & Palliative Care Registry in Collaboration with the American Academy of Home Care Medicine, Powered by Premier", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NHBPC17", "title": "Screening for Depression and Follow-up Plan in Home-Based Primary Care and Palliative Care Patients", "description": "Percentage of actively enrolled home-based primary care and palliative care patients who were screened for the presence of depression symptoms at enrollment and annually AND if positive, have a treatment plan for depression documented on the date of the positive screen.", "nqfId": null, "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Home-Based Primary Care & Palliative Care Registry in Collaboration with the American Academy of Home Care Medicine, Powered by Premier", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NHBPC2", "title": "Alcohol Problem Use Assessment & Brief Intervention 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 AND if positive, have a brief intervention for problematic alcohol use documented on the date of the positive assessment.", "nqfId": null, "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Home-Based Primary Care & Palliative Care Registry in Collaboration with the American Academy of Home Care Medicine, Powered by Premier", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NHBPC7", "title": "Delirium Assessment in Home-Based Primary Care and Palliative Care Patients: Medication List Reviewed & Offending Medications Discontinued (Multiperformance-Rate Measure)", "description": "Percentage of actively enrolled home-based primary care and palliative care patients with new diagnosis of altered mental status, delirium, or new or unexpected cognitive decline whose medication lists were reviewed for possible offending medications and whose use of medications was discontinued or justified. This measure will be calculated with two rates:\n \nRate 1: Percentage of patients whose medications lists were reviewed for possible offending medications.\nRate 2: Percentage of patients with offending medications whose use of offending medications was discontinued or justified.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "intermediateOutcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Home-Based Primary Care & Palliative Care Registry in Collaboration with the American Academy of Home Care Medicine, Powered by Premier", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "reviewed", "description": "Percentage of patients whose medications lists were reviewed for possible offending medications." }, { "name": "overall", "description": "Percentage of patients with offending medications whose use of offending medications was discontinued or justified." } ], "submissionMethods": [ "registry" ] }, { "measureId": "NHBPC9", "title": "Referral to Hospice for Appropriate Home-Based Primary Care and Palliative Care Patients", "description": "Percentage of actively enrolled home-based primary care and palliative care patients with a prognosis of 6 months or less who were offered referral to hospice.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Home-Based Primary Care & Palliative Care Registry in Collaboration with the American Academy of Home Care Medicine, Powered by Premier", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NOF12", "title": "Median Time to Pain Management for Long Bone Fracture", "description": "Median time from emergency department arrival to time of initial oral or parenteral pain medication administration for emergency department patients with a principal diagnosis of long bone fracture (LBF).", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "National Osteoporosis Foundation Quality Improvement Registry, Powered by Premier, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "NOF13", "title": "Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older", "description": "Percentage of patients aged 50 years or older with fracture of the hip, spine or distal radius that had a central DXA measurement ordered or performed or pharmacologic therapy prescribed", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Osteoporosis Foundation Quality Improvement Registry, Powered by Premier, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR1", "title": "Notification to the ordering provider requesting myoglobin or CK-MB in the diagnosis of suspected acute myocardial infarction (AMI)", "description": "Percentage of ordering providers who have ordered a myoglobin or CK-MB for greater than 10% of the patients who have a diagnosis of suspected AMI, that were informed by the laboratory these tests are not beneficial for patients with a diagnosis of suspected AMI.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR11", "title": "Rate of communicating results of an amended report with a major discrepancy to the responsible provider", "description": "Rate of communicating to the responsible provider the results of diagnostic reports that were amended due to a major discrepancy.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR12", "title": "Rate of cytopathology case review", "description": "Rate of retrospective review of all cytopathology cases.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR13", "title": "Rate of notification to clinical provider of a new diagnosis of malignancy", "description": "The rate of reporting to a responsible clinical provider from the pathologist when there is a new diagnosis of malignancy (other than squamous or basal cell carcinoma of the skin) from a pathology specimen", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR14", "title": "Frozen Section Diagnosis within 20 Minutes of Receipt in Lab (Single Specimen, Single Block Frozen Section)", "description": "The proportion of all single specimen, single block frozen sections for which a diagnosis is reported within 20 minutes of receipt in the laboratory.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR2", "title": "Notification to the ordering provider requesting thyroid screening tests other than only a Thyroid Stimulating Hormone (TSH) test in the initial screening of a patient with a suspected thyroid disorder", "description": "Percentage of ordering providers who ordered thyroid screening tests other than only a TSH in greater than 10% of their patients for the evaluation of a patient with suspected non-neoplastic thyroid disease, who were informed by the laboratory these tests are not beneficial for the initial diagnosis of thyroid disease.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR3", "title": "Notification to the ordering provider requesting amylase testing in the diagnosis of suspected acute pancreatitis", "description": "Percentage of ordering providers who ordered an amylase test in greater than 10% of their patients for the evaluation of a patient with acute pancreatitis, who were informed by the laboratory this test is not beneficial for the diagnosis of pancreatitis.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR4", "title": "Time interval: critical value reporting for chemistry", "description": "Measurement of the time interval beginning with the time results are verified for any of the following Sodium, Potassium, Chloride, Calcium-total, Bicarbonate - CO2, Ammonia, Total Bilirubin - Newborn, Arterial Blood Gases - pH, PO2, PCO2, Glucose, Glucose - Newborn tests until the critical value is reported by the laboratory. (Reporting done via phone, or secure electronic transmission, such as text messaging, messaging through Laboratory Information Systems, Electronic Health Records systems, or email with read receipt functionality). When notification is sent by email, performance met is contingent on read receipt received. If a read receipt is not received, this should be considered as performance not met.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR5", "title": "Time interval: critical value reporting for cerebrospinal fluid - white blood cell (CSF - WBC)", "description": "Measurement of the time interval beginning with the time results are verified (clinical) until the critical value is reported by the laboratory for CSF-WBC. (Done via phone, or secure electronic transmission, such as text messaging, messaging through Laboratory Information Systems, Electronic Health Records systems, or email with read receipt functionality). When notification is sent by email, performance met is contingent on read receipt received. If a read receipt is not received this should be considered as performance not met.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR6", "title": "Time interval: critical value reporting for toxicology", "description": "Measurement of the time interval beginning with the time results are verified until the critical value is reported by the laboratory for Carbamazepine, Phenobarbital, and Acetaminophen toxicology tests. (Reporting done via phone, or secure electronic transmission, such as text messaging, messaging through Laboratory Information Systems, Electronic Health Records systems, or email with read receipt functionality). When notification is sent by email, performance met is contingent on read receipt received. If a read receipt is not received this should be considered as performance not met.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR7", "title": "Time interval: critical value reporting for troponin", "description": "Measurement of the time interval beginning with the time results are verified for Troponin (CPT - 84484) until the critical value is reported by the laboratory. (Reporting done via phone, email with read receipt functionality, or text). When notification is sent by email, performance met is contingent on read receipt received. If a read receipt is not received this should be considered as performance not met.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR8", "title": "Rate of review of slides with high-grade squamous intraepithelial lesion (HSIL) with negative cervical biopsies", "description": "Rate of review all available slides with high-grade squamous epithelial lesion (HSIL) Pap tests with subsequent cervical biopsies negative for dysplasia within 6 months.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPQR9", "title": "Rate of follow up letter after high-grade squamous intraepithelial lesion (HSIL) pap test", "description": "Rate of follow up notifications submitted to the responsible provider when a patient has the diagnosis of high-grade squamous epithelial lesion (HSIL) on a Pap test and has had no cervical biopsies within 6 months (+/- 2 weeks).", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "National Pathology Quality Registry (NPQR)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NHCR5", "title": "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)", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "New Hampshire Colonoscopy Registry (NHCR)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OBERD22", "title": "Post Stroke Outcome and Follow-Up", "description": "This measure quantifies the quality of care of stroke patients by means of their change in score on a stroke-related patient reported outcome (PRO) instrument. The patient must have a diagnosis of index ischemic stroke (IS), intracerebral hemorrhage (ICH), or transient ischemic attack (TIA); must have completed the PRO instrument at discharge or within 7 days of the diagnosed event (the \"baseline\" measurement); and must have completed the same PRO between 90 and 120 days after the baseline (the \"follow-up\" measurement)", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Oberd", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OBERD23", "title": "Health Related Quality of Life: Patient Defined Outcomes", "description": "The finger dexterity goal of a guitarist is poorly measured by a standard question about difficulty buttoning a coat. The object of this measure is to track changes in the level of difficulty, which patients experience in performing a self-defined activity that is especially meaningful to their own quality of life intervention. The level of difficulty is rated on a 0-10 points scale for the self-defined activity and will be assessed based on comparison between pre-intervention and post-intervention scores.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Oberd", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OBERD25", "title": "Tracking Satisfaction Improvement with CG-CAHPS", "description": "This is an outcome measure: it measures actual improvement in patient satisfaction. It uses the same scoring approach, which underlies the statistics which CG-CAHPS reports annually. Each individual form is scored as the percentage of questions for which the EC received the top mark; the two most recent forms for each patient are compared; the percentage of patients whose scores did not go down is reported.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Oberd", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OBERD28", "title": "Hip Functional Outcomes", "description": "Percentage of patients 18 years of age and older who completed a baseline and, within the CY(calendar year) reporting period of Jan. 1, 20xx - Dec.31, 20xx, a follow-up patient-reported hip functional assessment (e.g. Harris Hip Score, HOOS, HOOS-PS, HOOS Jr, Oxford Hip, or equivalent CAT assessment if available) that showed a statistically significant improvement in comparison to initial assessment or who had already reported a score in which there is no room for statistical improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Oberd", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OBERD31", "title": "Quality of Life-Mental Health Outcomes", "description": "Percentage of patients 18 years of age and older who completed a baseline and, within the CY(calendar year) reporting period of Jan. 1, 20xx - Dec.31, 20xx, follow-up quality of life (QoL) patient-reported outcomes assessment (VR-12, SF-12, SF-36, PROMIS Global 10 or equivalent Computer Adaptive Test (CAT) assessment if available) which yielded a mental component score that showed a statistically significant improvement in comparison to initial assessment or who had already reported a score in which there is no room for statistical improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented. In addition, the AAOS Quality Outcomes Work Group recommends that QoL PROs in the clinical setting can lead to improved care.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "patientEngagementExperience", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Oberd", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OBERD32", "title": "Quality of Life - Physical Health Outcomes", "description": "Percentage of patients 18 years of age and older who completed a baseline and, within the CY(calendar year) reporting period of Jan. 1, 20xx - Dec.31, 20xx, a follow-up quality of life (QoL) patient-reported outcomes assessment (VR-12, SF-12, SF-36, PROMIS Global 10 or equivalent Computer Adaptive Test (CAT) assessment if available) which yielded a physical component score that showed a statistically significant improvement in comparison to initial assessment or who had already reported a score in which there is no room for statistical improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented. In addition, the AAOS Quality Outcomes Work Group recommends that QoL PROs in the clinical setting can lead to improved care.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "patientEngagementExperience", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Oberd", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OBERD33", "title": "Patient Acceptable Symptom State Outcomes", "description": "Percentage of patients 18 years or older who completed a baseline and, within the CY(calendar year) reporting period of Jan. 1, 20xx - Dec.31, 20xx, a follow-up Patient Acceptable Symptoms State (PASS) assessment that showed a statistically significant improvement in comparison to initial assessment or who had already reported a score in which there is no room for statistical improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Oberd", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OBERD34", "title": "Upper Extremity Functional Outcomes", "description": "Percentage of patients 18 years of age and older who completed a baseline and, within the CY(calendar year) reporting period of Jan. 1, 20xx - Dec.31, 20xx, a follow-up patient-reported upper extremity functional assessment (e.g. PROMIS Upper Extremity, ASES, ASES - elbow, Oxford Shoulder Score, Oxford Instability Score, Penn Shoulder Score, Boston questionnaire, DASH, Quick DASH, PRWE, or equivalent CAT assessment if available) that showed a statistically significant improvement in comparison to initial assessment or who had already reported a score in which there is no room for statistical improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Oberd", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SPINETRACK4", "title": "Percent of patients meeting SCB thresholds for back or neck pain", "description": "Calculation of the percent of patients who meet the substantial clinical benefit (SCB) thresholds for improvement in back or neck pain following a spine surgical intervention (cervical or lumbar)", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SpineTRACK Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SPINETRACK6", "title": "Percent of patients meeting SCB thresholds for pain-related disability (ODI/NDI)", "description": "Calculation of the percent of patients who meet the substantial clinical benefit (SCB) thresholds for improvement in pain-related disability following a spine surgical intervention (cervical or lumbar)", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SpineTRACK Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ONSQIR16", "title": "Recommendation for Exercise to Adult Cancer Survivors", "description": "Percentage of patients aged 18 or older with a current or prior diagnosis of cancer who receive an individualized recommendation for >= 150 minutes of moderate intensity or >= 75 minutes of high intensity cardio type exercise weekly along with two sessions of resistance and/or flexibility exercise at any visit during the measurement period.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Oncology QCDR Powered by Premier, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ONSQIR18", "title": "Goal Setting and Attainment for Cancer Survivors", "description": "Percentage of patients aged 18 years and older who completed the final component of cancer treatment that have at least one post-treatment goal documented and progress toward goal attainment documented within 12 months of completing the final component of cancer treatment.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "patientEngagementExperience", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Oncology QCDR Powered by Premier, Inc.", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ONSQIR21", "title": "Patient Reported Health-Related Quality of Life (HRQOL) during Treatment for Advanced Cancer", "description": "Percentage of patients aged 18 and older with an active diagnosis of advanced cancer (Stage III or Stage IV) receiving chemotherapy and/or immunotherapy for treatment of cancer, who have HRQOL assessed on the FACT-G (Version 4) or PROMIS Global Health short form (Version 1.2) at least twice during the measurement period at least 90 days apart, where the most recent total score indicates the same or better quality of life.\n\nTwo rates are reported:\nRate 1: Percentage of patients aged 18 and older with an active diagnosis of advanced cancer (Stage III or Stage IV) receiving chemotherapy and/or immunotherapy for treatment of cancer, who have HRQOL assessed on the FACT-G (Version 4) or PROMIS Global Health short form (Version 1.2) at least twice during the measurement period at least 90 days apart.\nRate 2: Percentage of patients aged 18 and older with an active diagnosis of advanced cancer (Stage III or Stage IV) receiving chemotherapy and/or immunotherapy for treatment of cancer, who have HRQOL assessed on the FACT-G (Version 4) or PROMIS Global Health short form (Version 1.2) at least twice during the measurement period at least 90 days apart, where the most recent total score indicates the same or better quality of life.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Oncology QCDR Powered by Premier, Inc.", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "diagnosis", "description": "Percentage of patients aged 18 and older with an active diagnosis of advanced cancer (Stage III or Stage IV) receiving chemotherapy and/or immunotherapy for treatment of cancer, who have HRQOL assessed on the FACT-G (Version 4) or PROMIS Global Health short form (Version 1.2) at least twice during the measurement period at least 90 days apart." }, { "name": "overall", "description": "Percentage of patients aged 18 and older with an active diagnosis of advanced cancer (Stage III or Stage IV) receiving chemotherapy and/or immunotherapy for treatment of cancer, who have HRQOL assessed on the FACT-G (Version 4) or PROMIS Global Health short form (Version 1.2) at least twice during the measurement period at least 90 days apart, where the most recent total score indicates the same or better quality of life." } ], "submissionMethods": [ "registry" ] }, { "measureId": "ONSQIR22", "title": "PCR Test with MR2 or greater result (BCR-ABL1 transcript level <= 1% [IS]) for patients receiving TKI for at least 6 months for Chronic Myelogenous Leukemia", "description": "Percentage of patients aged 18 and older with chronic myelogenous leukemia who are receiving TKI therapy for at least 6 months, who have at least 1 PCR test performed with the most recent result equal to or greater than MR2 (BCR-ABL1 transcript level <= 1% [IS]) during the measurement period.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "intermediateOutcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Oncology QCDR Powered by Premier, Inc.", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ONSQIR23", "title": "Assessment for and management of immune-related adverse events during cancer treatment with checkpoint inhibitors (ICPi)", "description": "Percentage of patients aged 18 and older receiving a checkpoint inhibitor (ICPi) for cancer experiencing immune-related adverse events of documented grade 3+ diarrhea OR documented grade 3+ hypothyroidism OR documented grade 3+ dermatitis OR documented grade 3+ pneumonitis AND for each adverse event, there is guideline concordant intervention (per ASCO/NCCN guideline) during the measurement period.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "intermediateOutcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Oncology QCDR Powered by Premier, Inc.", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OEIS2", "title": "Emergent transfer from an outpatient, ambulatory surgical center, or office setting", "description": "Rate of emergent transfer from an outpatient, ASC, or office setting to an acute care facility as a result of an invasive peripheral vascular intervention.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Outpatient Endovascular and Interventional Society National Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OEIS6", "title": "Appropriate non-invasive arterial testing for patients with intermittent claudication who are undergoing a LE peripheral vascular intervention", "description": "Proportion of patients with non-invasive evaluations present/available prior to LE peripheral vascular interventions in patients with intermittent claudication.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Outpatient Endovascular and Interventional Society National Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "OEIS7", "title": "Structured Walking Program Prior to Intervention for Claudication", "description": "Proportion of patients who completed a structured walking program of a duration not less than 12 weeks prior to undergoing peripheral arterial intervention in patients with claudication", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Outpatient Endovascular and Interventional Society National Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP10", "title": "Blood Laboratory Samples for Potassium Determination with Hemolysis Drawn in ED", "description": "Percentage of blood laboratory samples for potassium determination drawn in the emergency department (ED) with hemolysis.\nINSTRUCTIONS: This measure is to be reported each time an ED patient having blood drawn for potassium determination during the performance period. This measure is an episode-of-care measure; the level of analysis for this measure is every potassium laboratory test during the measurement period. For example, for every laboratory test performed to evaluate a potassium level, the sample should be evaluated for hemolysis.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "intermediateOutcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP11", "title": "Accurate Human Epidermal Growth Factor Receptor 2 (HER2) Tumor Evaluation and Repeat Evaluation in Patients with Breast Carcinoma", "description": "Percentage of surgical pathology reports for breast carcinoma with appropriate human epidermal growth factor receptor 2 (HER2) breast tumor evaluation \nThree rates are submitted.\n1. Percentage of surgical pathology reports for breast carcinoma with a quantitative breast tumor evaluation using HER2 IHC or ISH, that had an HER2 result derived using the ASCO/CAP guideline optimal scoring algorithm\n2. Percentage of surgical pathology reports for breast carcinoma with an equivocal HER2 result obtained using the ASCO/CAP guideline optimal scoring algorithm that had a subsequent repeat HER2 test completed\n3. Percentage of surgical pathology reports for breast carcinoma with a quantitative breast tumor evaluation using HER2 IHC or ISH, that had an HER2 result derived using the ASCO/CAP guideline optimal scoring algorithm AND when an equivocal HER2 result was obtained, had a subsequent repeat HER2 test completed \nPerformance rate 3 is the reported rate\nINSTRUCTIONS: This measure is to be reported each time a breast carcinoma report is finalized during the performance period. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP12", "title": "Accurate Human Epidermal Growth Factor Receptor 2 (HER2) Tumor Evaluation and Repeat Evaluation in Patients with Gastroesophageal Adenocarcinoma", "description": "Percentage of patients diagnosed with gastroesophageal adenocarcinoma (GEA) cancer (primary or metastatic) for which biopsies, resection, or metastatic specimens have HER2 evaluation conducted using the current ASCO/CAP recommended manual system or computer-assisted system consistent with the optimal algorithm.\nINSTRUCTIONS: This measure should be submitted when quantitative HER2 evaluation is conducted during the performance period for patients with gastroesophageal adenocarcinoma. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.\nThis measure has two performance rates that contribute to the overall performance score:\n1. Percentage of all pathology reports for GEA cancer biopsies or resection specimens (primary or metastasis) for patients with known GEA that have HER2 immunohistochemistry (IHC) evaluation conducted using the current ASCO/CAP recommended optimal scoring algorithm completed.\n2. Percentage of pathology reports GEA cancer patients with equivocal (IHC 2+) human epidermal growth factor receptor 2 (HER2) testing result that had a follow-up HER2 evaluation completed using in-situ hybridization (ISH). \nThe overall performance score is a weighted average of: (Numerator 1 + Numerator 2)/(Denominator 1 + Denominator 2).", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP13", "title": "Anaplastic Lymphoma Kinase (ALK) Biomarker Testing to Inform Clinical Management and Treatment Decisions in Patients with Non-small Cell Lung Cancer", "description": "Percentage of non-small cell lung cancer (NSCLC) surgical pathology reports that include anaplastic lymphoma kinase (ALK) mutation status.\nINSTRUCTIONS: This measure is to be reported each time a non-small cell lung cancer specimen pathology report is finalized during the performance period. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.\nThe results of ALK testing of a specimen are frequently needed at some point during a patient's treatment. Pathologists are uniquely well positioned at the time of signing out the surgical pathology report to detail the disposition of ALK testing for that specimen. Referring physicians depend on both the pathologists' interpretations of and any recommendations for tests in order to provide quality patient care. If the status is not indicated in each pathology report for the patient, unnecessary repeat testing may be performed delaying treatment and increasing cost. This measure monitors the success of pathologists in effectively communicating this important information for the purpose of care coordination and efficient use of resources.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP14", "title": "Appropriate Formalin Fixation Time (6 - 72 hours) of Breast Cancer Specimens to Ensure Accurate Ancillary Testing Results", "description": "Percentage of breast cancer specimens (cytology, biopsy and/or resection) in which the total fixation time in formalin is between 6-72 hours.\nINSTRUCTIONS: This measure is to be reported each time a breast cancer specimen is processed during the performance period. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP15", "title": "BRAF Biomarker Testing to Inform Clinical Management and Treatment Decisions in Patients with Metastatic Colorectal Adenocarcinoma", "description": "Percentage of metastatic colorectal adenocarcinoma surgical pathology reports that address biomarker evaluation for BRAF mutation.\nINSTRUCTIONS: This measure is to be reported each time a primary colorectal adenocarcinoma pathology report is finalized during the performance period. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.\nThe results of BRAF testing of a sample are frequently needed at some point during a patient's treatment. Pathologists are uniquely well positioned at the time of signing out the surgical pathology report to detail the disposition of BRAF testing for that sample. Referring physicians depend on both the pathologists' interpretations of and any recommendations for tests in order to provide quality patient care. If the status is not indicated in each pathology report for the patient, important tests may be missed or unnecessary repeat testing may be performed delaying treatment and increasing cost. This measure monitors the success of pathologists in effectively communicating this important information for the purpose of care coordination and efficient use of resources.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP16", "title": "Epidermal Growth Factor Receptor (EGFR) Biomarker Testing to Inform Clinical Management and Treatment Decisions in Patients with Non-small Cell Lung Cancer", "description": "Percentage of non-small cell lung cancer (NSCLC) surgical pathology reports that include epidermal growth factor receptor (EGFR) mutation status. \nINSTRUCTIONS: This measure is to be reported each time a non-small cell lung cancer specimen pathology report is finalized during the performance period. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.\nThe results of EGFR testing of a specimen are frequently needed at some point during a patient's treatment. Pathologists are uniquely well positioned at the time of signing out the surgical pathology report to detail the disposition of EGFR testing for that specimen. A significant number of patients with early-stage disease will progress to advanced disease in which EGFR mutation results can eventually guide their therapy. Referring physicians depend on both the pathologists' interpretations of and any recommendations for tests in order to provide quality patient care. If the status is not indicated in each pathology report for the patient, unnecessary repeat testing may be performed delaying treatment and increasing cost. This measure monitors the success of pathologists in effectively communicating this important information for the purpose of care coordination and efficient use of resources.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP17", "title": "FMS-like Tyrosine 3-Internal Tandem Duplication (FLT3-ITD) Biomarker Testing to Inform Clinical Management and Treatment Decisions in Patients with Acute Myeloid Leukemia", "description": "Percentage of acute myeloid leukemia (AML) pathology reports that include FMS-like tyrosine 3-internal tandem duplication (FLT3-ITD) status. \nINSTRUCTIONS: This measure is to be reported each time an acute myeloid leukemia specimen pathology report is finalized during the performance period. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.\nThe results of FLT3-ITD testing of a specimen are frequently needed at some point during a patient's treatment. Pathologists are uniquely well positioned at the time of signing out the surgical pathology report to detail the disposition of FLT3-ITD testing for that specimen. Referring physicians depend on both the pathologists' interpretations of and any recommendations for tests in order to provide quality patient care. If the status is not indicated in each pathology report for the patient, unnecessary repeat testing may be performed delaying treatment and increasing cost. This measure monitors the success of pathologists in effectively communicating this important information for the purpose of care coordination and efficient use of resources.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP18", "title": "Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing to Inform Clinical Management and Treatment Decisions in Patients with Primary or Metastatic Colorectal Carcinoma", "description": "Percentage of all primary or metastatic colorectal carcinoma surgical pathology reports that address the status of biomarker evaluation for mismatch repair (MMR) by immunohistochemistry (biomarkers MLH1, MSH2, MSH6 and PMS2), or microsatellite instability (MSI) by DNA-based testing status, or both.\nINSTRUCTIONS: This measure is to be reported each time a primary or metastatic colorectal carcinoma pathology report is finalized during the performance period. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.\nThe results of MMR/MSI testing of a sample are frequently needed at some point during a patient's treatment. Pathologists are uniquely well positioned at the time of signing out the surgical pathology report to detail the disposition of MMR/MSI testing for that sample. Referring physicians depend on both the pathologists' interpretations of and any recommendations for tests in order to provide quality patient care. If the status is not indicated in each pathology report for the patient, important tests may be missed or unnecessary repeat testing may be performed delaying treatment and increasing cost. This measure monitors the success of pathologists in effectively communicating this important information for the purpose of care coordination and efficient use of resources.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP19", "title": "ROS 1 Biomarker Testing to Inform Clinical Management and Treatment Decisions in Patients with Non-small Cell Lung Cancer", "description": "Percentage of non-small cell lung cancer (NSCLC) surgical pathology reports that include ROS1 mutation status.\nINSTRUCTIONS: This measure is to be reported each time a non-small cell lung cancer specimen pathology report is finalized during the performance period. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.\nThe results of ROS1 testing of a specimen are frequently needed at some point during a patient's treatment. Pathologists are uniquely well positioned at the time of signing out the surgical pathology report to detail the disposition of ROS1 testing for that specimen. Referring physicians depend on both the pathologists' interpretations of and any recommendations for tests in order to provide quality patient care. If the status is not indicated in each pathology report for the patient, unnecessary repeat testing may be performed delaying treatment and increasing cost. This measure monitors the success of pathologists in effectively communicating this important information for the purpose of care coordination and efficient use of resources.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP20", "title": "High Risk HPV Testing and p16 Scoring in Surgical Specimens for Patients with Oropharyngeal Squamous Cell Carcinoma (OPSCC)", "description": "Percentage of surgical pathology reports for invasive oropharyngeal squamous cell carcinoma (OPSCC) with HR-HPV testing by surrogate marker p16 performed AND that include quantitative p16 immunohistochemistry (IHC) results.\nINSTRUCTIONS: This measure has two performance rates that contribute to the overall performance score:\n1. Percentage of surgical pathology reports for invasive OPSCC with HR-HPV testing by surrogate marker p16 IHC performed.\n2. Percentage of surgical pathology reports for invasive OPSCC with HR-HPV testing by surrogate marker p16 IHC performed AND that include quantitative p16 IHC results based on the >=70% nuclear and cytoplasmic staining. \nThis measure is to be reported each time an invasive OPSCC pathology report is finalized during the performance period. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. \nThe overall performance score submitted is a simple average of: (Performance rate 1 + Performance rate 2)/2.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP21", "title": "High Risk HPV Testing in Cytopathology Specimens for Patients with Oropharyngeal Squamous Cell Carcinoma (OPSCC)", "description": "Percentage of cytopathology reports from samples of known or suspected oropharyngeal squamous cell carcinoma or metastatic SCC of unknown primary that include high-risk HPV testing status.\nINSTRUCTIONS: This measure is to be reported each time a cytopathology report from samples of known or suspected oropharyngeal squamous cell carcinoma or metastatic SCC of unknown primary is finalized during the performance period. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP22", "title": "Turnaround Time (TAT) - Biopsies", "description": "Percentage of final pathology reports for biopsies that meet the maximum 2 business day turnaround time (TAT) requirement (Report Date - Accession Date <= 2 business days).\nINSTRUCTIONS: This measure is to be reported each time a biopsy is performed during the performance period. It is anticipated that eligible clinicians providing the pathology services for procedures will submit this measure.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP23", "title": "Cancer Protocol Elements and Turnaround Time for Carcinoma and Carcinosarcoma of the Endometrium", "description": "Percentage of all eligible carcinoma and carcinosarcoma of the endometrium specimens for which all required data elements of the Cancer Protocol are included \nAND \nmeet the maximum 4 business day turnaround time (TAT) requirement (Report Date - Accession Date <= 4 business days). \nINSTRUCTIONS: This measure has two performance rates that contribute to the overall performance score:\n1. Percent of cases for which all required data elements of the cancer protocol are included.\n2. Percent of cases that meet the maximum 4 business day turnaround time.\nThe overall performance score submitted is a weighted average of: (Performance rate 1 x 70%)+(Performance rate 2 x 30%).", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP24", "title": "Cancer Protocol Elements and Turnaround Time for Carcinoma of the Intrahepatic Bile Ducts", "description": "Percentage of all eligible carcinoma of the intrahepatic bile ducts specimens:\n- Hepatic resection\n- Partial hepatic resection\n- Total hepatic resection\nfor which all required data elements of the Cancer Protocol are included \nAND\nmeet the maximum 4 business day turnaround time (TAT) requirement (Report Date - Accession Date <= 4 business days). \nINSTRUCTIONS: This measure has two performance rates that contribute to the overall performance score:\n1. Percent of cases for which all required data elements of the cancer protocol are included.\n2. Percent of cases that meet the maximum 4 business day turnaround time.\nThe overall performance score submitted is a weighted average of: (Performance rate 1 x 70%)+(Performance rate 2 x 30%).", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP25", "title": "Cancer Protocol Elements and Turnaround Time for Carcinoma of the Pancreas", "description": "Percentage of all eligible pancreatic exocrine carcinoma (including small cell and large cell (poorly differentiated) neuroendocrine carcinoma) specimens:\n- Partial Pancreatectomy\n- Total Pancreatectomy\n- Pancreaticoduodenectomy (Whipple Resection)\nfor which all required data elements of the Cancer Protocol are included \nAND \nmeet the maximum 4 business day turnaround time (TAT) requirement (Report Date - Accession Date <= 4 business days).\nINSTRUCTIONS: This measure has two performance rates that contribute to the overall performance score:\n1. Percent of cases for which all required data elements of the cancer protocol are included.\n2. Percent of cases that meet the maximum 4 business day turnaround time.\nThe overall performance score submitted is a weighted average of: (Performance rate 1 x 70%)+(Performance rate 2 x 30%).", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP26", "title": "Cancer Protocol Elements and Turnaround Time for Hepatocellular Carcinoma", "description": "Percentage of all eligible hepatocellular carcinoma specimens:\n- Hepatic resection\n- Partial hepatic resection\n- Complete hepatic resection\nfor which all required data elements of the Cancer Protocol are included \nAND \nmeet the maximum 4 business day turnaround time (TAT) requirement (Report Date - Accession Date <= 4 business days).\nINSTRUCTIONS: This measure has two performance rates that contribute to the overall performance score:\n1. Percent of cases for which all required data elements of the cancer protocol are included.\n2. Percent of cases that meet the maximum 4 business day turnaround time.\nThe overall performance score submitted is a weighted average of: (Performance rate 1 x 70%)+(Performance rate 2 x 30%).", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP27", "title": "Cancer Protocol Elements and Turnaround Time for Invasive Carcinoma of Renal Tubular Origin", "description": "Percentage of all eligible kidney resections specimens:\n- Partial Nephrectomy\n- Total Nephrectomy\n- Radical Nephrectomy\nfor which all required data elements of the Cancer Protocol are included \nAND\nmeet the maximum 4 business day turnaround time (TAT) requirement (Report Date - Accession Date <= 4 business days). \nINSTRUCTIONS: This measure has two performance rates that contribute to the overall performance score:\n1. Percent of cases for which all required data elements of the cancer protocol are included.\n2. Percent of cases that meet the maximum 4 business day turnaround time.\nThe overall performance score submitted is a weighted average of: (Performance rate 1 x 70%)+(Performance rate 2 x 30%).", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP28", "title": "Helicobacter pylori Status and Turnaround Time", "description": "Percentage of stomach biopsy cases with gastritis that addresses presence or absence of Helicobacter pylori included \nAND\nmeet the maximum 2 business day turnaround time (TAT) requirement (Report Date - Accession Date <= 2 business days).\nINSTRUCTIONS: This measure has two performance rates that contribute to the overall performance score:\n1. Percent of cases in which presence or absence of Helicobacter pylori is addressed.\n2. Percent of cases that meet the maximum 2 business day turnaround time.\nThe overall performance score submitted is a weighted average of: (Numerator 1 + Numerator 2)/(Denominator 1 + Denominator 2).", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP8", "title": "Turnaround Time (TAT) - Lactate", "description": "The rate of cases in which the turnaround time (TAT) target for lactate tests ordered in the emergency department (ED) is met.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CAP9", "title": "Turnaround Time (TAT) - Troponin", "description": "The rate of cases in which the turnaround time (TAT) target for troponin tests ordered in the emergency department (ED) is met.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Pathologists Quality Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "FORCE20", "title": "Review of Functional Status Assessment for Patients with Osteoarthritis", "description": "Percentage of patients 18 years of age and older with osteoarthritis who completed baseline or follow-up patient-reported functional status assessment and reviewed the results of this assessment with their care provider.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "QI FORCE", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "FORCE21", "title": "Review of Pain Status Assessment for Patients with Osteoarthritis", "description": "Percentage of patients 18 years of age and older with osteoarthritis who completed baseline and follow-up patient-reported pain status assessment and reviewed the results of this assessment with their care provider.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "QI FORCE", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "WCHQ10", "title": "Diabetes Care All or None Outcome Measure: Optimal Control", "description": "The percentage of diabetes patients 18 through 75 years of age who had the following during the 12-month measurement period: \n All or None Outcome Measure (Optimal Control) composite of A1C <8.0%, BP <130/80, Tobacco Non-User, Statin Use, and Daily Aspirin or Other Antiplatelet for diabetes patients with IVD.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "intermediateOutcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Physician Compass", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "WCHQ15", "title": "Screening For Osteoporosis", "description": "The percentage of women age 65 through 85 who had a minimum of one bone densitometry test at age 60 or above or have a diagnosis of osteoporosis or osteopenia.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Physician Compass", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "WCHQ32", "title": "Controlling High Blood Pressure: eGFR Test Annually", "description": "The percentage of essential hypertension patients 18 through 85 years of age who had the following during the 12 month measurement period: \n\nAn eGFR (Estimated Glomerular Filtration Rate) test annually", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Physician Compass", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "WCHQ9", "title": "Diabetes Care All or None Process Measure: Optimal Testing", "description": "The percentage of diabetes patients 18 through 75 years of age who had the following during the 12-month measurement period: \n All or None Process Measure (Optimal Testing) composite of two A1C's, one Kidney Function \nMonitoring Test and one eGFR Test", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Physician Compass", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACCPIN10", "title": "Hypertension: Blood Pressure Treatment and Control for Stage 2 Hypertensive Patients", "description": "Proportion of patients with hypertension who were prescribed antihypertensive medications or who had adequately controlled blood pressure", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "PINNACLE Registry and Diabetes Collaborative Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACCPIN7", "title": "Peripheral Artery Disease: Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk", "description": "Percentage of Patients 18-75 years of age with PAD who were offered moderate-to-high intensity statin", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "PINNACLE Registry and Diabetes Collaborative Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACCPIN8", "title": "Hypertension: Blood Pressure Control for Stage 1 or 2 Hypertensive Patients", "description": "Proportion of patients with hypertension who had adequately controlled blood pressure", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "intermediateOutcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "PINNACLE Registry and Diabetes Collaborative Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACCPIN9", "title": "Hypertension: Blood Pressure Treatment and Control for High Risk Patients", "description": "Proportion of patients with both hypertension and a >= 10% CVD risk OR high-risk diagnosis (i.e. ASCVD, chronic kidney disease, diabetes) who were prescribed antihypertensive medication or who had adequately controlled blood pressure", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "PINNACLE Registry and Diabetes Collaborative Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ARCO15", "title": "Diabetes: Nutritional, Weight Loss Counseling, Reduction of Sedentary Behavior", "description": "Percentage of diabetic patients receiving nutritional counseling", "nqfId": null, "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ReportingMD", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PIMSH1", "title": "Advance Care Planning in Stage 4 Disease", "description": "Percentage of patients with metastatic (stage 4) cancer who have a documented ACP discussion in the first 6 months after metastatic diagnosis.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "patientEngagementExperience", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Practice Insights by McKesson Specialty Health in Collaboration with The US Oncology Network", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PIMSH4", "title": "Oncology: Patient-Reported Pain Improvement", "description": "Percentage of cancer patients currently receiving chemotherapy or radiation therapy who report significant pain improvement (high to moderate, moderate to low, or high to low) within 30 days", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Practice Insights by McKesson Specialty Health in Collaboration with The US Oncology Network", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PIMSH5", "title": "Oncology: Supportive Care Drug Utilization in Last 14 Days of Life", "description": "Percentage of patients receiving supportive care drugs (limited to colony stimulating factors, bone health and supplemental iron medications) during the 14 days prior to and including the date of death.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "efficiency", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Practice Insights by McKesson Specialty Health in Collaboration with The US Oncology Network", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PIMSH8", "title": "Oncology: Mutation Testing for Lung Cancer (i.e. EGFR, alk, ROS) Completed Prior to Start of Therapy", "description": "Percentage of lung cancer patients who received mutation testing for all actionable biomarkers at stage 4 diagnosis of NSCLC, including EGFR, BRAF, ROS1 mutations, ALK rearrangements, and PD-L1 expression", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Practice Insights by McKesson Specialty Health in Collaboration with The US Oncology Network", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PINC1", "title": "Risk-adjusted 30 day Readmission for Acute Myocardial Infarction", "description": "Readmission to the same hospital for all causes within 30 days from the date of discharge of the index Acute Myocardial Infarction (AMI) admission", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Premier Clinician Performance Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "PINC2", "title": "Risk-adjusted 30 day Readmission for Heart Failure", "description": "Readmission to the same hospital for all causes within 30 days from the date of discharge of the index Heart Failure (HF) admission", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Premier Clinician Performance Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "PINC3", "title": "Risk-adjusted 30 day Readmission for Pneumonia", "description": "Readmission to the same hospital for all causes within 30 days from the date of discharge of the index Pneumonia (PN) admission", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Premier Clinician Performance Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "PINC33", "title": "Risk-Adjusted Average Length of Inpatient Hospital Stay for Acute Myocardial Infarction", "description": "The average (geometric mean) hospital length of stay in days relative to the expected geometric mean length of stay of the Acute Myocardial Infarction (AMI) population of inpatients for the measurement year.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Premier Clinician Performance Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "PINC34", "title": "Risk-Adjusted Average Length of Inpatient Hospital Stay for Heart Failure", "description": "The average (geometric mean) hospital length of stay in days relative to the expected geometric mean length of stay of the Heart Failure (HF) population of inpatients for the measurement year.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Premier Clinician Performance Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "PINC35", "title": "Risk-Adjusted Average Length of Inpatient Hospital Stay for Pneumonia", "description": "The average (geometric mean) hospital length of stay in days relative to the expected geometric mean length of stay of the Pneumonia (PN) population of inpatients for the measurement year.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Premier Clinician Performance Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "PINC4", "title": "Risk-adjusted 30 day Inpatient Mortality for Acute Myocardial Infarction", "description": "Mortality during hospital admission for patients with a Principal Diagnosis of Acute Myocardial Infarction (AMI).", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Premier Clinician Performance Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "PINC5", "title": "Risk-adjusted 30 day Inpatient Mortality for Heart Failure", "description": "Mortality during hospital admission for patients with a Principal Diagnosis of Heart Failure (HF)", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Premier Clinician Performance Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "PINC6", "title": "Risk-adjusted 30 day Inpatient Mortality for Pneumonia", "description": "Mortality during hospital admission for patients with a Principal Diagnosis of Pneumonia (PN)", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Premier Clinician Performance Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "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.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ReportingMD", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PP2", "title": "Follow-Up After Hospitalization for Schizophrenia (7- and 30-day)", "description": "The percentage of discharges for individuals 18 - 85 years of age who were hospitalized for treatment of schizophrenia and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported.\nRate 1: The percentage of individuals who received follow-up within 30 days of discharge\nRate 2: The percentage of individuals who received follow-up within 7 days of discharge", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "PsychPRO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "overall", "description": "The percentage of individuals who received follow-up within 30 days of discharge" }, { "name": "7days", "description": "The percentage of individuals who received follow-up within 7 days of discharge" } ], "submissionMethods": [ "registry" ] }, { "measureId": "PP4", "title": "Risky Behavior Assessment or Counseling by Age 18 Years", "description": "The percentage of adolescents with documentation of assessment or counseling for risky behavior by the age of 18 years. Four rates are reported: Rate 1: Risk Assessment or Counseling for Alcohol Use, Rate 2: Risk Assessment or Counseling for Tobacco Use, Rate 3: Risk Assessment or Counseling for Other Substance Use, and Rate 4: Risk Assessment or Counseling for Sexual Activity.", "nqfId": null, "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "PsychPRO", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "weightedAverage", "strata": [ { "name": "counselalcohol", "description": "Risk Assessment or Counseling for Alcohol Use," }, { "name": "counseltobacco", "description": "Risk Assessment or Counseling for Tobacco Use," }, { "name": "counselsubstance", "description": "Risk Assessment or Counseling for Other Substance Use, and" }, { "name": "counselactivity", "description": "Risk Assessment or Counseling for Sexual Activity." } ], "submissionMethods": [ "registry" ] }, { "measureId": "PP5", "title": "Bipolar disorder: the percentage of patients diagnosed and treated for bipolar disorder who are monitored for change in their symptom complex within 12 weeks of initiating treatment; AND if there is no change or deterioration in symptoms, a revised care plan is documented following the 12 week monitoring phase", "description": "This measure is used to assess the percentage of patients diagnosed and treated for bipolar disorder who are monitored for change in their symptom complex within 12 weeks of initiating treatment AND who are provided with a documented revised care plan after the 12 week monitoring phase, if there is no change or deterioration in their symptoms.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "PsychPRO", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "PP7", "title": "Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC)", "description": "This measure is used to assess the percentage of children and adolescents 1 to 17 years of age who were on two or more concurrent antipsychotic medications.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "PsychPRO", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "QOPI11", "title": "Combination chemotherapy received within 4 months of diagnosis by women under 70 with AJCC stage IA (T1c) to III ER/PR negative breast cancer", "description": "Percentage of adult women under 70 with a diagnosis of AJCC stage IA (T1c) to III ER/PR negative breast cancer, who receive combination chemotherapy within 4 months of diagnosis", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "QOPI Reporting Registry (QCDR) Brought to you by ASCO and ASTRO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "QOPI15", "title": "GCSF administered to patients who received chemotherapy for metastatic cancer (Lower Score -Better)", "description": "Percentage of adult patients with metastatic cancer who are administered chemotherapy and who received a colony stimulating factor (Lower score - Better)", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "QOPI Reporting Registry (QCDR) Brought to you by ASCO and ASTRO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "QOPI23", "title": "Concurrent Chemoradiation for Patients with a Diagnosis of Stage IIIB NSCLC", "description": "Percentage of patients, regardless of age, with a diagnosis of Stage IIIB NSCLC receiving concurrent chemoradiation.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "QOPI Reporting Registry (QCDR) Brought to you by ASCO and ASTRO", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "QOPI5", "title": "Chemotherapy administered to patients with metastatic solid tumor with performance status of 3, 4, or undocumented (Lower Score - Better)", "description": "Percentage of patients with metastatic solid tumors and a performance status of 3, 4, or undocumented who receive chemotherapy (Lower score is better)", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "QOPI Reporting Registry (QCDR) Brought to you by ASCO and ASTRO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPA11", "title": "Unplanned Readmission Following Spine Procedure within the 30-Day Postoperative Period", "description": "Percentage of patients aged 18 years and older who had any unplanned readmission for spine-related procedure within the 30-day postoperative period", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Quality Outcomes Database (QOD)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPA12", "title": "Selection of Prophylactic Antibiotic Prior to Spine Procedure", "description": "Percentage of patients aged 18 years and older undergoing an index spine-related procedure with the indications for prophylactic antibiotics who had an order for antimicrobial prophylaxis", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Quality Outcomes Database (QOD)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPA18", "title": "Smoking Assessment and Cessation Coincident With Spine-Related Therapies", "description": "Percentage of patients aged 18 years and older who were assessed for tobacco use prior to spine-related therapy(-ies) and who received cessation counseling intervention if identified as a tobacco user.", "nqfId": null, "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Quality Outcomes Database (QOD)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NPA19", "title": "Body Mass Assessment and Follow-up Coincident With Spine-Related Therapies", "description": "Percentage of patients aged 18 years and older with a weight and height recorded in the medical record at the time of initial evaluation and/or treatment of spine-related disorder and, if the most recent body mass index (BMI) is outside of normal parameters (BMI _ 23 and < 30 for patients 65 years and older; BMI >= 18.5 and < 25 for patients 18-64 years of age), a follow-up plan is documented (example: \"Patient referred to nutrition counseling for BMI above normal parameters\").", "nqfId": null, "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Quality Outcomes Database (QOD)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "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.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Quality Outcomes Database (QOD)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RCOIR1", "title": "CKD 3-5 Patients Seen at the Recommended Frequency Levels", "description": "CKD 3-5 Patients Seen at Recommended Frequency Levels is the percentage of patients aged 18\nyears and older with a diagnosis for CKD 3-5 that have been seen by the nephrologist or\nnephrologist's team member in the office setting within the lowest value of the suggested frequency\nrange per the Kidney Disease: Improving Global Outcomes (KDIGO).\nRate 1: New CKD stage 3 patients Rate 2: New CKD stage 4 patients Rate 3: New CKD stage 5 patients", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "weightedAverage", "strata": [ { "name": "three", "description": "New CKD stage 3 patients" }, { "name": "four", "description": "New CKD stage 4 patients" }, { "name": "five", "description": "New CKD stage 5 patients" } ], "submissionMethods": [ "registry" ] }, { "measureId": "RCOIR10", "title": "Upper Extremity Edema Improvement", "description": "Upper Extremity Edema Improvement is the percentage of patients with ESRD that present with upper\nextremity edema and report an improvement within 48 hours after an intervention has been performed.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RCOIR12", "title": "Tunneled Hemodialysis Catheter Success", "description": "Tunneled Hemodialysis Catheter Success is the percentage of patients with ESRD that had insertion or replacement of a central venous access device during the past 12 months who received a full dialysis treatment within 72 hours of catheter insertion or replacement.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RCOIR3", "title": "CKD 3-5 Patients with a Urine ACR or Urine PCR Lab Test", "description": "CKD 3-5 Patients with a Urine ACR or Urine PCR Lab Test is the percentage of patients aged 18\nyears and older with a diagnosis for CKD 3-5 and not receiving Renal Replacement Treatment that\nhave had a urine albumin to creatinine ratio lab test (ACR) or urine protein to creatinine ratio lab test\n(PCR) performed within the measurement period.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RCOIR4", "title": "CKD 4-5 Patients with Transplant Referral", "description": "CKD 4-5 Patients with Transplant Referral is the percentage of patients aged 18 - 65 years with\na diagnosis for CKD 4-5 who are referred to a transplant center for kidney transplant evaluation.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "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.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RCOIR7", "title": "Improved Access Site Bleeding", "description": "Improved Access Site Bleeding is the percentage of patients with ESRD and a vascular access site\nthat presented for prolonged bleeding, received an intervention, and subsequently reported a\nreduction in post-dialysis bleeding.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RPAQIR13", "title": "Rate of Timely Documentation Transmission to Dialysis Unit/Referring Physician", "description": "Percentage of patients aged 18 years and older for whom documentation is sent to the dialysis unit or referring physician within two days of the procedure completion or consultation by an interventional nephrologist, radiologist or vascular surgeon.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal Physicians Association Kidney Quality Improvement Program - Powered by Premier, Inc", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RPAQIR14", "title": "Arteriovenous Graft Thrombectomy Success Rate", "description": "Percentage of clinically successful arteriovenous graft (AVG) thrombectomies for patients aged 18 years and older.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal Physicians Association Kidney Quality Improvement Program - Powered by Premier, Inc", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RPAQIR15", "title": "Arteriovenous Fistulae Thrombectomy Success Rate", "description": "Percentage of clinically successful arteriovenous fistulae (AVF) thrombectomies for patients aged 18 years and older on maintenance hemodialysis dialysis", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal Physicians Association Kidney Quality Improvement Program - Powered by Premier, Inc", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RPAQIR1", "title": "Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy", "description": "Percentage of patients aged 18 years and older with a diagnosis of CKD (Stages 1-5, not receiving RRT) and proteinuria who were prescribed ACE inhibitor or ARB therapy within a 12-month period.", "nqfId": "1662", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal Physicians Association Kidney Quality Improvement Program - Powered by Premier, Inc", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RPAQIR16", "title": "Peritoneal Dialysis Catheter Success Rate", "description": "Percentage of clinically successful peritoneal dialysis (PD) catheter placements in patients aged 18 and older.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal Physicians Association Kidney Quality Improvement Program - Powered by Premier, Inc", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RPAQIR17", "title": "Peritoneal Dialysis Catheter Exit Site Infection Rate", "description": "Percentage of patients aged 18 years and older with an exit site infection within 2 weeks of a peritoneal dialysis (PD) catheter invasive intervention.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Renal Physicians Association Kidney Quality Improvement Program - Powered by Premier, Inc", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RPAQIR18", "title": "Advance Directives Completed", "description": "Percentage of patients aged 18 years and older with a diagnosis of Stage 3, 4 & 5 chronic kidney disease (CKD) or end stage renal disease (ESRD) who have advance directives and/or end of life medical orders completed based on their preferences.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal Physicians Association Kidney Quality Improvement Program - Powered by Premier, Inc", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RPAQIR4", "title": "Arteriovenous Fistula Rate", "description": "Percentage of calendar months within a 12-month period during which patients aged 18 years and older with a diagnosis of end-stage renal disease (ESRD) and receiving maintenance hemodialysis are using an autogenous arteriovenous (AV) fistula with two needles in an outpatient dialysis facility.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal Physicians Association Kidney Quality Improvement Program - Powered by Premier, Inc", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RPAQIR5", "title": "Transplant Referral", "description": "Percentage of patients aged 18 -75 years old with a diagnosis of end-stage renal disease (ESRD) on hemodialysis or peritoneal dialysis for 90 days or longer who are referred to a transplant center for kidney transplant evaluation within a 12-month period.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal Physicians Association Kidney Quality Improvement Program - Powered by Premier, Inc", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "RPAQIR9", "title": "Advance Care Planning (Pediatric Kidney Disease)", "description": "Percentage of patients aged 17 years and younger with a diagnosis of ESRD on hemodialysis or peritoneal dialysis for whom there is documentation of a discussion regarding advance care planning.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Renal Physicians Association Kidney Quality Improvement Program - Powered by Premier, Inc", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACR7", "title": "Gout: Serum Urate Target", "description": "Percentage of patients aged 18 and older with a diagnosis of gout treated with urate-lowering therapy (ULT) for at least 12 months, whose most recent serum urate result is less than 6.8 mg/dL.", "nqfId": "2549e", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "intermediateOutcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "RISE (Rheumatology Informatics System for Effectiveness)", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ARCO16", "title": "Dyspnea or Heart Failure: Use of BNP or NT- pro BNP screening", "description": "Percent of patients with dyspnea or heart failure that have received BNP or NT- pro BNP screening as a tool to support clinical decision making in regards to the diagnosis or disease severity of heart failure, especially in the setting of clinical uncertainty.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ReportingMD", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ARCO17", "title": "Heart Failure: Use of Aldosterone Antagonists and Diuretics for Symptom Control", "description": "Percent of heart failure patients with reduced ejection fraction < 40% on aldosterone antagonists. Aldosterone receptor antagonists (or mineralocorticoid receptor antagonists) are recommended in patients with NYHA class II-IV HF and who have LVEF of 40% or less, unless contraindicated, to reduce morbidity and mortality.\n\nRate 1: Patient prescribed Aldosterone receptor antagonists (or mineralocorticoid receptor antagonists). Numerator note: Careful monitoring of potassium, renal function, and diuretic dosing should be performed at initiation and closely followed thereafter to minimize risk of hyper kalemia and renal insufficiency. (Level of Evidence: A). \nRate 2: Patient using diuretics for symptom control", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ReportingMD", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "simpleAverage", "strata": [ { "name": "aldosterone", "description": "Patient prescribed Aldosterone receptor antagonists (or mineralocorticoid receptor antagonists). Numerator note: Careful monitoring of potassium, renal function, and diuretic dosing should be performed at initiation and closely followed thereafter to minimize risk of hyper kalemia and renal insufficiency. (Level of Evidence: A)." }, { "name": "diuretics", "description": "Patient using diuretics for symptom control" } ], "submissionMethods": [ "registry" ] }, { "measureId": "ARCO18", "title": "Heart Failure: Counseling on Self-care, Including Monitoring Blood Pressure, Weight, Sodium Intake, and Physical Activity", "description": "Percentage of Heart Failure patients receiving counseling on self-care including monitoring of blood pressure, weight, sodium intake, and physical activity", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ReportingMD", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NJIISMD1", "title": "Critical Result: Pulmonary Embolism", "description": "Efficiency of reporting Critical Result: Pulmonary Embolism diagnosed on radiology exams", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD in Collaboration with Suncoast RHIO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NJIISMD11", "title": "Critical Result: New Deep Venous Thrombosis (DVT)", "description": "Efficiency of reporting Critical Result: New DVT diagnosed on radiology exams", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD in Collaboration with Suncoast RHIO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NJIISMD17", "title": "Result Requiring Follow Up Protocol", "description": "Timeliness of notification in cases of diagnostic exams when there is a recommendation to obtain a follow up exam.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD in Collaboration with Suncoast RHIO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NJIISMD19", "title": "Critical Result: Cord Compression", "description": "Efficiency of reporting Critical Result: Cord Compression diagnosed on radiology exams", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD in Collaboration with Suncoast RHIO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NJIISMD2", "title": "Critical Result: Intracranial Hemorrhage", "description": "Efficiency of reporting Intracranial Hemorrhage diagnosed on radiology exams", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD in Collaboration with Suncoast RHIO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NJIISMD20", "title": "Critical Result: CTA of GI bleed", "description": "Efficiency of reporting Critical Result: GI Bleed diagnosed on CT Angiogram exams", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD in Collaboration with Suncoast RHIO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NJIISMD21", "title": "Critical Result: Positive nuclear bleeding scan", "description": "Efficiency of reporting Critical Result: Positive Nuclear Bleeding Scan", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD in Collaboration with Suncoast RHIO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NJIISMD22", "title": "Critical Result: Acute Ocular injury", "description": "Efficiency of reporting Critical Result: Acute Ocular Injury diagnosed on radiology exams", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD in Collaboration with Suncoast RHIO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NJIISMD3", "title": "Critical Result: Aortic Dissection", "description": "Efficiency of reporting Critical Result: Aortic Dissection diagnosed on radiology exams", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD in Collaboration with Suncoast RHIO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NJIISMD8", "title": "Critical Result: Occlusive Intracranial Stroke", "description": "Efficiency of reporting Critical Result: Occlusive intracranial stroke diagnosed on radiology exams", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD in Collaboration with Suncoast RHIO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NJIISMD9", "title": "Critical Result: Placental abruption", "description": "Efficiency of reporting Critical Result: Placental abruption diagnosed on radiology exams", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD in Collaboration with Suncoast RHIO", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMD23", "title": "Urgent Result: Breast Specimen Radiography", "description": "Efficiency of reporting radiographic findings of Breast Specimen Radiography", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD in Collaboration with Suncoast RHIO", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMD24", "title": "Critical Result: Testicular Torsion", "description": "Efficiency of reporting radiographic findings of Testicular Torsion", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD in Collaboration with Suncoast RHIO", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMD25", "title": "Critical Result: Subdural hematoma", "description": "Efficiency of reporting radiographic findings of Subdural hematoma", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD in Collaboration with Suncoast RHIO", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMD26", "title": "GI Radiography Result Notification\n-Critical Result: Bowel Obstruction\n-Critical Result: Sigmoid Volvulus\n-Critical Result: Pneumoperitoneum", "description": "-Efficiency of reporting radiographic findings of Bowel Obstruction\n-Efficiency of reporting radiographic findings of Sigmoid Volvulus\n-Efficiency of reporting radiographic findings of pneumoperitoneum", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD in Collaboration with Suncoast RHIO", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMD27", "title": "Chest Imaging Result Notification:\n-Critical Result: Pneumothorax\n-Critical Result: Tension Pneumothorax\n-Follow Up Result: Suspicious Lung Nodule", "description": "-Efficiency of reporting radiographic findings of Pneumothorax\n-Efficiency of reporting radiographic findings of Tension Pneumothorax\n-Efficiency of reporting radiographic findings of Suspicious Lung Nodule", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD in Collaboration with Suncoast RHIO", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMD28", "title": "Musculoskeletal Radiology Result Notification:\n-Critical Result: C-Spine fracture\n-Critical Result: Rib fracture\n-Urgent Result: Osteomyelitis\n-Urgent Result: Meniscal tear", "description": "-Efficiency of reporting radiographic findings of C-Spine fracture\n-Efficiency of reporting radiographic findings of rib fracture\n-Efficiency of reporting radiographic findings of osteomyelitis\n-Efficiency of reporting radiographic findings of meniscal Tear", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD in Collaboration with Suncoast RHIO", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMD29", "title": "Incidental Finding Closed Loop Work Up Rate", "description": "When radiologists discover imaging exam findings that require additional workup, how often did the follow up exam take place?", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD in Collaboration with Suncoast RHIO", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "SMD30", "title": "Aortic Aneurism Result Notification", "description": "Efficiency of reporting radiographic findings of Aortic Aneurism", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD in Collaboration with Suncoast RHIO", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMD31", "title": "Ectopic Pregnancy Critical Results\n-Critical Result: Ruptured Ectopic Pregnancy\n-Critical Result: Ectopic Pregnancy", "description": "-Efficiency of reporting Critical Result: Ruptured ectopic pregnancy diagnosed on radiology exams\n-Efficiency of reporting Critical Result: Ectopic Pregnancy diagnosed on radiology exams", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD in Collaboration with Suncoast RHIO", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMD32", "title": "Pathology Peer Review Duration (composite measure)\nStrata:\n-Breast cancer\n-Lung cancer\n-Melanoma\n-Colorectal cancer", "description": "Pathologists review peer review exams from a review queue. This measure evaluates pathologists' performance initiating the peer review process.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD in Collaboration with Suncoast RHIO", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMD33", "title": "Radiology Peer Review Duration (composite measure)\nStrata:\n-Pneumonia\n-Pulmonary nodule\n-Pulmonary embolism\n-Stroke\n-Intracranial hemorrhage", "description": "Radiologists review peer review exams from a review queue. This measure evaluates radiologists' performance initiating the peer review process.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SaferMD in Collaboration with Suncoast RHIO", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMD34", "title": "Image Guided Lung Biopsy Complication Rate", "description": "Frequency of complications following imaging guided percutaneous lung biopsies", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "SaferMD in Collaboration with Suncoast RHIO", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMD35", "title": "Thyroid biopsy - percentage of non-diagnostic samples", "description": "What percentage of image guided thyroid biopsies were non-diagnostic?", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "SaferMD in Collaboration with Suncoast RHIO", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACS18", "title": "Patient Frailty Evaluation", "description": "Percentage of patients age 65 and older who have been evaluated for frailty prior to an elective operation", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Surgeon Specific Registry ACS Surgical Phases of Care Measures", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACS23", "title": "Unplanned Hospital Readmission within 30 Days of Principal Procedure", "description": "Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Surgeon Specific Registry ACS Surgical Phases of Care Measures", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "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.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "SCG Health", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SCG10", "title": "Treatment and Management Outcomes of Acute Wounds and/or Ulcers", "description": "The treatment and management of outcomes by percentage of patients, regardless of age, with a suspected infection of an acute wound and/or ulcer that required treatment and management over two or more encounters during the performance period", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SCG Health", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "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", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "SCG Health", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SCG3", "title": "Outcome Assessment for Patients Prescribed Foot Orthosis for Ambulation and Functional Improvement", "description": "Percentage of patients 18 years and older with a deformity of the foot or forefoot, who had at least two medical visits during the performance period, and for whom a foot orthosis was prescribed to assist with ambulation AND report a significant improvement in ambulation and function with the orthosis using a standardized tool within the reporting period", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "SCG Health", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SCG8", "title": "Pre-surgical screening for depression", "description": "Percentage of patients, regardless of age, undergoing surgical, therapeutic or diagnostic procedures under anesthesia where the patient a received a formal pre-surgical screening for depression using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SCG Health", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SCG9", "title": "Avoidance of Inappropriate Emergency Department Use", "description": "Percentage of patients, 18 years and older, who were referred to an appropriate site of service, avoiding the Emergency Department", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SCG Health", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "SMX10", "title": "Prevalence and Severity of High Blood Pressure Among Children (SoDH) - Blood Pressure screening for children 1-13 years of age and 14 - 19 years of age", "description": "Percentage of children 1 -13 years of age, and 14 - 19 years of age who were had a blood pressure reading taken and if greater than 130/80 had a follow-up plan documented\nPerformance rates: Rate 1: For patients ages 1-13, had at least 1 blood pressure reading in the measurement period and if the reading was greater than 130/80 had a follow-up plan documented. Rate 2: For patients ages 14 - 19, had at least 1 blood pressure reading in the measurement period and if the reading was greater than 130/80 had a follow-up plan documented.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SpectraMedix eMeasures360™ QCDR", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "weightedAverage", "strata": [ { "name": "13under", "description": "For patients ages 1-13, had at least 1 blood pressure reading in the measurement period and if the reading was greater than 130/80 had a follow-up plan documented." }, { "name": "14over", "description": "For patients ages 14 - 19, had at least 1 blood pressure reading in the measurement period and if the reading was greater than 130/80 had a follow-up plan documented." } ], "submissionMethods": [ "registry" ] }, { "measureId": "SMX11", "title": "Screening for Risk Factors for Adult Cardiovascular Disease in Children (SoDH) - Dyslipidemia screening for children ages 9 -11 and post-puberty ages 17-21", "description": "Screening for Risk factors for adult cardiovascular disease - Percent of patients ages 9 -11 that had a baseline HDL-C screening or ages 17 -21 that had a baseline HDL-C or LDL-C screening test and if out of range, had a follow-up plan documented.\nPerformance rates: Rate 1: For Patients 9 -11 who had an HDL-C screening and if result is greater than 40 mg/dl then a follow-up plan is documented. Rate 2: For Patients 17 - 21 who either had a HDL-C screening and if result is greater than 40 mg/dl then a follow-up plan is documented, OR had a LDL-C screening and if result is less than 130 mg/dl had a follow-up plan documented.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SpectraMedix eMeasures360™ QCDR", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "weightedAverage", "strata": [ { "name": "9to11", "description": "For Patients 9 -11 who had an HDL-C screening and if result is greater than 40 mg/dl then a follow-up plan is documented." }, { "name": "17to21", "description": "For Patients 17 - 21 who either had a HDL-C screening and if result is greater than 40 mg/dl then a follow-up plan is documented, OR had a LDL-C screening and if result is less than 130 mg/dl had a follow-up plan documented." } ], "submissionMethods": [ "registry" ] }, { "measureId": "SPINETRACK5", "title": "Percent of patients meeting SCB thresholds for leg or arm pain", "description": "Calculation of the percent of patients who meet the substantial clinical benefit (SCB) thresholds for improvement in leg or arm pain following a spine surgical intervention (cervical or lumbar)", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "SpineTRACK Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "STS1", "title": "Prolonged Length of Stay Following Coronary Artery Bypass Grafting", "description": "Percentage of patients aged 18 years and older undergoing isolated CABG with an inpatient postoperative length of stay of more than 14 days whether patient is alive or dead at discharge", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "STS National Database", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "STS11", "title": "Lobectomy - Air Leak Greater than 5 Days", "description": "Percentage of patients who underwent lobectomy surgery for lung cancer who have a post-operative air leak greater than 5 days.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "STS National Database", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "STS3", "title": "Prolonged Length of Stay for Coronary Artery Bypass Grafting (CABG) + Valve Replacement", "description": "Percentage of patients aged 18 years and older undergoing CABG + valve replacement with an inpatient postoperative length of stay of more than 14 days whether patient is alive or dead at discharge", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "STS National Database", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "STS5", "title": "Prolonged Length of Stay following Valve Surgery", "description": "Percentage of patients aged 18 years and older undergoing isolated valve surgery with an inpatient postoperative length of stay of more than 14 days whether patient is alive or dead at discharge", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "STS National Database", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "STS7", "title": "Patient Centered Surgical Risk Assessment and Communication for Cardiac Surgery", "description": "Percentage of patients age 18 and older undergoing a non-emergency risk modeled cardiac surgery procedure that had personalized risk assessment using the STS risk calculator and discussed those risks with the surgeon.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "STS National Database", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "STS8", "title": "Operative Mortality for Esophageal Resection", "description": "Percentage of patients who underwent esophageal resection surgery for esophageal cancer who suffer an operative mortality.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "STS National Database", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACS16", "title": "Preventative Care and Screening: Tobacco Screening and Cessation Intervention", "description": "Percentage of patients age 18 or older who are active tobacco users who receive tobacco screening AND are offered cessation counseling at least 2 months prior to elective surgical procedure in order to delay the procedure until smoking cessation is possibly achieved.", "nqfId": null, "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Surgeon Specific Registry ACS Surgical Phases of Care Measures", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACS20", "title": "Optimal Postoperative Communication Plan and Patient Care Coordination Composite", "description": "Percentage of patients, age 18 years or older, who are brought from their home or normal living environment and who are taken to the operating room for an elective surgical intervention under regional anesthesia, MAC, and/or general anesthesia who have been documented for having all four of the following patient care communication and care coordination planning components addressed at the beginning of the postoperative phase of care:\n1.\tA postoperative care plan is established, addressing mobilization, pain management, diet, resumption of preoperative medications, management of drains/catheters/invasive lines, and wound care.\n2.\tA postoperative review of the patient goals of care that were expressed preoperatively and updating those goals of care as appropriate.\n3. A postoperative care coordination with the patient's primary/referring provider regarding the surgery within\n30 days following surgery.\n4.\tA postoperative patient care communication plan with the patient and/or patient's family regarding the surgery and plan for care after discharge.", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Surgeon Specific Registry ACS Surgical Phases of Care Measures", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACS21", "title": "Post-Acute Recovery Composite", "description": "Percentage of patients age 18 or older who are taken to the operating room for an elective intervention under regional, MAC, and/or general anesthesia who have been documented for having all two post-acute components addressed at the beginning of the post-discharge phase of care:\n1.\tA post-discharge review of the patient goals of care that were expressed preoperatively and updating those goals of care as appropriate occurring after discharge up until 30 days following discharge date.\n2.\tA post-discharge follow-up encounter within 30 days updating patient improvements in mobility, pain control, diet, resumption of home medications, wound care, and management of cutaneous/invasive devices (drains,\nIV lines, etc).", "nqfId": null, "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Surgeon Specific Registry ACS Surgical Phases of Care Measures", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACS22", "title": "Unplanned Reoperation within the 30 Day Postoperative Period", "description": "Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Surgeon Specific Registry ACS Surgical Phases of Care Measures", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACS24", "title": "Surgical Phases of Care Patient-Reported Outcome Composite Measure", "description": "Composite measure consisting of 12 items intended to measure the constructs of Surgeon Communication Before Surgery, Surgical Goals of Care, Satisfaction with Information, and Postoperative Care Coordination from the patient's perspective. Of these 12 items, 9 originate from the CAHPS Surgical Care Survey (S-CAHPS). Specifically, these 9 items are questions 3, 9, 11, 17, 26, 27, 31, 33, and 34 from the original S-CAHPS survey. Three (3) additional items are included to appropriately measure Goals of Care; these questions ask whether the surgeon discussed what the patient hoped to gain from surgery, whether the surgeon discussed how surgery would affect their daily activities, and what life might look like for the patient in the long-term. Please see the attachment for all 12 items in full.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "patientEngagementExperience", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Surgeon Specific Registry ACS Surgical Phases of Care Measures", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACS25", "title": "Surgical Site Infection (SSI)", "description": "Percentage of patients aged 18 years and older who had a surgical site infection (SSI).", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Surgeon Specific Registry ACS Surgical Phases of Care Measures", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "NIPM18", "title": "CHANGE IN PATIENT REPORTED QUALITY OF LIFE FOLLOWING EPIDURAL LYSIS OF ADHESIONS", "description": "Measurement of the change in patient reported quality of life following epidural lysis of adhesions. Quality of life measurement on standardized scale includes pain, mobility, analgesic medication use, and activities of daily living.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "NIPM19", "title": "CHANGE IN PATIENT REPORTED QUALITY OF LIFE AND FUNCTIONAL STATUS FOLLOWING MEDIAL BRANCH RADIOFREQUENCY ABLATION", "description": "Measurement of the change in patient reported quality of life following medial branch radiofrequency ablation. Quality of life measurement on standardized scale includes mobility, analgesic medication use, psychological well-being and activities of daily living.\nPerformance rate: 2 (cervical/thoracic, lumbar/sacral)", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "NIPM20", "title": "CHANGE IN PATIENT REPORTED PAIN AND FUNCTIONAL STATUS FOLLOWING SPINAL CORD STIMULATOR IMPLANTATION", "description": "Measurement of the change in patient reported quality of life following spinal cord stimular implantation for failed back surgery syndrome. Quality of life measurement on standardized scale includes pain, mobility, analgesic medication use, psychological well-being and activities of daily living.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "NIPM21", "title": "REDUCTION IN PATIENT REPORTED PAIN FOLLOWING MEDIAL BRANCH RADIOFREQUENCY ABLATION", "description": "Measurement of reduction in pain as reported by patients aged 18 years and older following medial branch radiofrequency ablation\n1. The percent reduction in pain score on a visual analog scale (0-10), comparing pre-procedure pain (recorded within 90 days prior to the procedure) and post-procedure pain (recorded within 120 days following the procedure) in the area targeted for treatment\n2. The reduction in pain as reported by the patient as a percent reduction in pain in the area targeted for treatment, comparing pre-procedure and post-procedure pain. Percent reduction in pain must be reported within 120 days following the procedure.\nPerformance rate: 2 (cervical/thoracic, lumbar/sacral)", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "NIPM22", "title": "CHANGE IN PATIENT REPORTED QUALITY OF LIFE FOLLOWING EPIDURAL CORTICOSTEROID INJECTION", "description": "Measurement of the change in patient reported quality of life following caudal, lumbar, thoracic, or cervical epidural corticosteroid injection. Quality of life measurement on standardized scale includes pain, mobility, psychological well-being, analgesic medication use, and activities of daily living.\nPerformance rate: 2 (cervical/thoracic, lumbar/sacral)", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "NIPM23", "title": "CHANGE IN PATIENT REPORTED QUALITY OF LIFE FOLLOWING MAJOR JOINT CORTICOSTEROID INJECTION", "description": "Measurement of the change in patient reported quality of life following major joint corticosteroid injection. Quality of life measurement on standardized scale includes pain, mobility, analgesic medication use, and activities of daily living.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "CDR2", "title": "Diabetic Foot Ulcer (DFU) Healing or Closure", "description": "Percentage of diabetic foot ulcers among patients age 18 or older that have achieved healing or closure within 6 months, stratified by the Wound Healing Index. Healing or closure is defined as complete epithelialization without drainage or the need for a dressing over the closed ulceration, although venous compression would still be required.\n\nThere are four rates reported for this measure.\nThree of the rates will be risk stratified into three buckets (minimum-maximum) which are the following:\nRate 1: 0.00 - 62.42\nRate 2: 62.42 - 73.19\nRate 3: 73.19 - 93.45\nRate 4: The average of the three risk stratified buckets which will be the performance rate in the XML submitted.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "bucket1", "description": "0.00 - 62.42" }, { "name": "bucket2", "description": "62.42 - 73.19" }, { "name": "bucket3", "description": "73.19 - 93.45" }, { "name": "overall", "description": "The average of the three risk stratified buckets which will be the performance rate in the XML submitted." } ], "submissionMethods": [ "registry" ] }, { "measureId": "CDR3", "title": "Plan of Care Creation for Diabetic Foot Ulcer (DFU) and Venous Leg Ulcer (VLU) not Achieving 30% Closure at 4 Weeks after undergoing treatment with CTP", "description": "A plan of care needs to be created for patients that fail to achieve 30% of wound closure within 4 weeks of the application of the first CTP, and will include review of whether appropriate usual care has been implemented as well as whether further CTP applications are indicated.\nRate 1: Diabetic Foot ulcer Rate 2: Venous leg ulcer", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "weightedAverage", "strata": [ { "name": "dfu", "description": "Diabetic Foot ulcer" }, { "name": "vlu", "description": "Venous leg ulcer" } ], "submissionMethods": [ "registry" ] }, { "measureId": "CDR5", "title": "Adequate Compression at each visit for Patients with VLUs", "description": "Percentage of venous leg ulcer visits among patients aged 18 years and older in which adequate compression is provided within the 12-month reporting period. Compression method should be appropriate to documented arterial supply. \n\nThere are four rates reported for this measure.\nThe four rates will be risk stratified into three buckets which are the following:\nRate 1: Normal arterial supply- No restrictions on type of compression\nRate 2: Compression bandaging with special considerations (e.g. short stretch bandaging, warnings to the patient to remove bandages if they feel too tight, etc.)\nRate 3: Compression bandaging not usually recommended\nRate 4: The average of the three risk stratified buckets which will be the performance rate in the XML submitted.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "normal", "description": "Normal arterial supply- No restrictions on type of compression" }, { "name": "considerations", "description": "Compression bandaging with special considerations (e.g. short stretch bandaging, warnings to the patient to remove bandages if they feel too tight, etc.)" }, { "name": "notrecommended", "description": "Compression bandaging not usually recommended" }, { "name": "overall", "description": "The average of the three risk stratified buckets which will be the performance rate in the XML submitted." } ], "submissionMethods": [ "registry" ] }, { "measureId": "CDR6", "title": "Venous Leg Ulcer (VLU) outcome measure: Healing or Closure", "description": "Percentage of venous leg ulcers among patients age 18 or older that have achieved healing or closure within 12 months, stratified by the Wound Healing Index. Healing or closure is defined as complete epithelialization without drainage or the need for a dressing over the closed ulceration, although venous compression would still be required.\n\nThere are four rates reported for this measure.\n\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.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "bucket1", "description": "0.00-73.24" }, { "name": "bucket2", "description": "73.24 - 80.26" }, { "name": "bucket3", "description": "80.26 - 87.21" }, { "name": "overall", "description": "The average of the three risk stratified buckets which will be the performance rate in the XML submitted." } ], "submissionMethods": [ "registry" ] }, { "measureId": "CDR8", "title": "Appropriate Use of hyperbaric oxygen therapy for patients with diabetic foot ulcers", "description": "Percentage of visits in which diabetic foot ulcers among patients aged 18 years and older received adequate off-loading during a 12-month reporting period.", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "CDR9", "title": "Appropriate Use of Cellular and/or Tissue Based Product (CTP) in diabetic foot ulcers (DFUs) or venous leg ulcer (VLUs) among patients 18 years or older", "description": "Percent of patients 18 or older with venous or diabetic foot ulcer who receive cellular and/or tissue based products (CTPs) appropriately. Appropriate Use of CTPs for a DFU or VLU is defined as use that adheres to Medicare coverage policy regarding the total number of applications over a specific time frame. While various Medicare policies indicate that a typical episode of care for a wound is 12 weeks, US Wound Registry data indicate this time frame is much too short. Additionally, the majority of patients have more than one wound. Coverage policies do not provide the guidance necessary to address all of these issues in our measure. Therefore, we will use a per wound basis, and assume the episode is the reporting period.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "USWR16", "title": "Major Amputation in Wagner 3, 4, or 5 Diabetic Foot Ulcers (DFUs) Treated with HBOT", "description": "Percentage of ulcers of patients aged 18 years or older with a diagnosis of a Wagner Grade 3, 4, or 5 diabetic foot ulcer (DFU) whose ulcer has an outcome of major amputation 6 months after completion of a course of HBOT, stratified by the Wound Healing Index.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "USWR22", "title": "Patient Reported Nutritional Assessment in Patients with Wounds and Ulcers", "description": "The percentage of patients aged 18 years and older with a diagnosis of a wound or ulcer of any type who self-report nutritional screening with a validated tool (such as the Self-MNA by Nestlé) within the 12-month reporting period.\n\t\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. A follow up plan is documented during the encounter from the patient reported nutritional assessment.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2017, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "USWR23", "title": "Non Invasive Arterial Assessment of patients with lower extremity wounds or ulcers for determination of healing potential", "description": "Percentage of patients aged 18 years or older with a non healing lower extremity wounds or ulcers that underwent a non-invasive arterial assessment once in a 12 month period, stratified by ABI, perfusion pressure, or oximetry.\n\nThere are four rates reported for this measure. The four rates will be risk stratified into three buckets which are the following:\nRate 1: No evidence of arterial disease and ischemia is not a contributor to non-healing\nRate 2: Possible arterial compromise (possible reduced flow), but the patient may still be able to heal the wound(s) or ulcer(s)\nRate 3: Evidence of arterial disease- patient should be referred to specialist for vascular assessment if not currently in the care of a vascular expert. Ischemia may be the reason the patient has failed to heal.\nRate 4: The average of the three risk stratified buckets which will be the performance rate in the XML submitted.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "noevidence", "description": "No evidence of arterial disease and ischemia is not a contributor to non-healing" }, { "name": "possiblecompromise", "description": "Possible arterial compromise (possible reduced flow), but the patient may still be able to heal the wound(s) or ulcer(s)" }, { "name": "evidence", "description": "Evidence of arterial disease- patient should be referred to specialist for vascular assessment if not currently in the care of a vascular expert. Ischemia may be the reason the patient has failed to heal." }, { "name": "overall", "description": "The average of the three risk stratified buckets which will be the performance rate in the XML submitted." } ], "submissionMethods": [ "registry" ] }, { "measureId": "USWR24", "title": "Patient Reported Experience of Care: Wound Outcome", "description": "All eligible patients with wounds or ulcers who completed of Wound Outcome Questionnaire who showed 10% improvement at discharge or transfer to another site of care during the 12 month reporting period.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "USWR25", "title": "Non-lower extremity Pressure Ulcer* (PU) Healing or Closure", "description": "Percentage of Stage 2, 3, or 4 pressure ulcers* (not on the lower extremity) among patients age 18 or older that achieve healing or closure within 6 months, stratified by the Wound Healing Index (WHI). Healing or closure may occur by delayed secondary intention or may be the result of surgical intervention (e.g. rotational flap or skin graft). Lower extremity pressure ulcers are not included in this measure because they commonly overlap with arterial and diabetic foot ulcers and require a separate risk stratification model.", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": true, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "USWR26", "title": "Patient Reported Outcome of late effects of radiation symptoms following treatment with Hyperbaric Oxygen Therapy (HBOT)", "description": "The percentage of patients 18 or older undergoing 10 or more treatments with HBOT for late effects of radiation whose self reported symptoms improve by at least 2 categories on the appropriate questionnaire (e.g. the Hematuria classification scale, the Chandler grade, the Cystitis questionnaire, the Bowel questionnaire, the head and neck questionnaire).", "nqfId": null, "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "U.S. Wound Registry", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "UREQA1", "title": "Ankylosing Spondylitis: Controlled Disease", "description": "Percentage of qualifying visits for patients aged 18 years and older with a diagnosis of ankylosing spondylitis for at least 6 months whose most recent BASDAI score is less than 4.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "UREQA (United Rheumatology Effectiveness and Quality Analytics)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "UREQA2", "title": "Ankylosing Spondylitis: Appropriate Pharmacologic Therapy", "description": "Percentage of patients aged 18 years and older with a first diagnosis of ankylosing spondylitis who are treated with nonsteroidal anti-inflammatory drugs (NSAIDs) before initiation of biologic therapy.", "nqfId": null, "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "UREQA (United Rheumatology Effectiveness and Quality Analytics)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "UREQA3", "title": "Controlled Gout for Patients on Urate-Lowering Pharmacologic Therapy", "description": "Percentage of patients aged 18 years and older with a diagnosis of gout treated with urate-lowering pharmacologic therapy for at least 6 months whose most recent serum urate result is less than 6.0 mg/dL.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "intermediateOutcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "UREQA (United Rheumatology Effectiveness and Quality Analytics)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "UREQA4", "title": "Folic or Folinic Acid Therapy for Patients Treated with Methotrexate", "description": "Percentage of patients aged 18 years and older being treated with methotrexate who are concomitantly treated with folic or folinic acid.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "UREQA (United Rheumatology Effectiveness and Quality Analytics)", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "UREQA6", "title": "Psoriatic Arthritis (PsA): Close Monitoring for Newly Diagnosed Patients", "description": "Percentage of patients aged 18 and older newly diagnosed with  psoriatic arthritis (PsA) within 6 months of date of service who have had a qualifying office visit at least every 90 days throughout the performance period.", "nqfId": null, "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "UREQA (United Rheumatology Effectiveness and Quality Analytics)", "firstPerformanceYear": 2019, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "VCMAHEMR1", "title": "Advance Care planning: Electronic submission of new POLST/MOLST/POST/MOST (\"orders for life-sustaining treatment\" or \"orders for scope of treatment\") into an eRegistry or patient medical record.", "description": "For patients with terminal conditions, physicians shall provide advance care planning to identify a patient's end-of-life treatment preferences and submit a new physician's order for life sustaining treatment form (\"POLST\"; also known as \"MOST\", \"MOLST\", or \"POST\" in some states) into an ePOLST Registry, making it accessible across the continuum of care.", "nqfId": null, "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Ventura County Medical Association-HEMR Advance care planning and POLST eRegistry", "firstPerformanceYear": 2018, "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] } ]