[ { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PCMH", "cehrtEligible": false, "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", "title": "Patient Centered Medical Home Attestation", "weight": null, "subcategoryId": null }, { "measureId": "ACI_INFBLO_1", "category": "aci", "title": "Prevention of Information Blocking Attestation", "description": "I have not knowingly and willfully take action to limit or restrict the interoperability of certified EHR technology.\nI have responded to requests to retrieve or exchange information—including requests from patients and other health care providers regardless of the requestor's affiliation or technology.\nI have implemented appropriate standards and processes to ensure that its certified EHR technology was connected in accordance with applicable law and standards, allowed patients timely access to their electronic health information; and supported exchange of electronic health information with other health care providers.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": 0, "isRequired": true, "isBonus": false, "measureSets": [], "objective": null, "reportingCategory": "preAttestation", "substitutes": [] }, { "measureId": "ACI_ONCDIR_1", "category": "aci", "title": "ONC Direct Review Attestation", "description": "I have (1) acknowledged the requirement to cooperate in good faith with ONC direct review health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received;\nAND (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": 0, "isRequired": true, "isBonus": false, "measureSets": [], "objective": null, "reportingCategory": "preAttestation", "substitutes": [] }, { "measureId": "ACI_ONCACB_1", "category": "aci", "title": "ONC-ACB Surveillance Attestation (Optional)", "description": "I have (1) Acknowledged the option to cooperate in good faith with ONC–ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC–ACB surveillance is received; and (2) If requested, cooperated in good faith with ONC–ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": 0, "isRequired": false, "isBonus": false, "measureSets": [], "objective": null, "reportingCategory": "preAttestation", "substitutes": [] }, { "measureId": "ACI_IACEHRT_1", "category": "aci", "title": "CEHRT Used", "description": "I attest that I have submitted an eligible Improvement Activity using Certified Electronic Health Record Technology (CEHRT).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": 10, "isRequired": false, "isBonus": true, "measureSets": [], "objective": null, "reportingCategory": "cehrtBonus", "substitutes": [] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "ACI_LVPP_1", "title": "E-Prescribing Exclusion", "description": "A MIPS eligible clinician (EC) who writes fewer than 100 permissible prescriptions during the performance period is eligible for exclusion from the required e-prescribing measure.", "isRequired": false, "weight": 0, "measureSets": [], "isBonus": false, "objective": "electronicPrescribing", "reportingCategory": "base", "substitutes": [ "ACI_EP_1", "ACI_TRANS_EP_1", "ACI_TRANS_LVPP_1" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "ACI_TRANS_LVPP_1", "title": "E-Prescribing Exclusion", "description": "A MIPS eligible clinician (EC) who writes fewer than 100 permissible prescriptions during the performance period is eligible for exclusion from the required e-prescribing measure.", "isRequired": false, "weight": 0, "measureSets": [ "transition" ], "isBonus": false, "objective": "electronicPrescribing", "reportingCategory": "base", "substitutes": [ "ACI_TRANS_EP_1", "ACI_LVPP_1", "ACI_EP_1" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "ACI_LVOTC_1", "title": "Send a Summary of Care Exclusion", "description": "Any MIPS eligible clinician who transfers a patient to another setting or refers a patient less than 100 times during the performance period.", "isRequired": false, "weight": 0, "measureSets": [], "isBonus": false, "objective": "healthInformationExchange", "reportingCategory": "base", "substitutes": [ "ACI_HIE_1", "ACI_TRANS_HIE_1", "ACI_TRANS_LVOTC_1" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "ACI_TRANS_LVOTC_1", "title": "Health Information Exchange Exclusion", "description": "Any MIPS eligible clinician who transfers a patient to another setting or refers a patient less than 100 times during the performance period.", "isRequired": false, "weight": 0, "measureSets": [ "transition" ], "isBonus": false, "objective": "healthInformationExchange", "reportingCategory": "base", "substitutes": [ "ACI_TRANS_HIE_1", "ACI_HIE_1", "ACI_LVOTC_1", "ACI_HIE_2", "ACI_LVITC_1" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "ACI_LVITC_1", "title": "Request/Accept Summary of Care Exclusion", "description": "Any MIPS eligible clinician who does not receive any transitions of care or referrals or have patient encounters in which the MIPS eligible clinician has never before encountered the patient during the performance period.", "isRequired": false, "weight": 0, "measureSets": [], "isBonus": false, "objective": "healthInformationExchange", "reportingCategory": "base", "substitutes": [ "ACI_HIE_2", "ACI_TRANS_HIE_1", "ACI_TRANS_LVOTC_1" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "cahps", "title": "CAHPS for MIPS SSM: Getting Timely Care, Appointments and Information", "description": "", "nationalQualityStrategyDomain": null, "measureType": "patientEngagementExperience", "measureId": "CAHPS_1", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0005", "isInverse": false, "strata": [], "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "cahps", "title": "CAHPS for MIPS SSM: How Well Providers Communicate", "description": "", "nationalQualityStrategyDomain": null, "measureType": "patientEngagementExperience", "measureId": "CAHPS_2", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0005", "isInverse": false, "strata": [], "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "cahps", "title": "CAHPS for MIPS SSM: Patient's Rating of Provider", "description": "", "nationalQualityStrategyDomain": null, "measureType": "patientEngagementExperience", "measureId": "CAHPS_3", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0005", "isInverse": false, "strata": [], "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "cahps", "title": "CAHPS for MIPS SSM: Access to Specialists", "description": "", "nationalQualityStrategyDomain": null, "measureType": "patientEngagementExperience", "measureId": "CAHPS_4", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [], "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "cahps", "title": "CAHPS for MIPS SSM: Health Promotion and Education", "description": "", "nationalQualityStrategyDomain": null, "measureType": "patientEngagementExperience", "measureId": "CAHPS_5", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [], "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "cahps", "title": "CAHPS for MIPS SSM: Shared Decision-Making", "description": "", "nationalQualityStrategyDomain": null, "measureType": "patientEngagementExperience", "measureId": "CAHPS_6", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [], "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "cahps", "title": "CAHPS for MIPS SSM: Health Status and Functional Status", "description": "", "nationalQualityStrategyDomain": null, "measureType": "patientEngagementExperience", "measureId": "CAHPS_7", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [], "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "cahps", "title": "CAHPS for MIPS SSM: Care Coordination", "description": "", "nationalQualityStrategyDomain": null, "measureType": "patientEngagementExperience", "measureId": "CAHPS_8", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [], "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "cahps", "title": "CAHPS for MIPS SSM: Courteous and Helpful Office Staff", "description": "", "nationalQualityStrategyDomain": null, "measureType": "patientEngagementExperience", "measureId": "CAHPS_9", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0005", "isInverse": false, "strata": [], "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "cahps", "title": "CAHPS for MIPS SSM: Helping You Take Medications as Directed", "description": "", "nationalQualityStrategyDomain": null, "measureType": "patientEngagementExperience", "measureId": "CAHPS_10", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [], "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "cahps", "title": "CAHPS for MIPS SSM: Stewardship of Patient Resources", "description": "", "nationalQualityStrategyDomain": null, "measureType": "patientEngagementExperience", "measureId": "CAHPS_11", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [], "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "cahps", "title": "CAHPS for MIPS SSM: Between Visit Communication", "description": "", "nationalQualityStrategyDomain": null, "measureType": "patientEngagementExperience", "measureId": "CAHPS_12", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [], "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Diabetes Mellitus (DM) Composite (All or Nothing Scoring) ", "description": "Composite of DM-2 (NQF 0059): Diabetes: Homoglobin A1c (HbA1c) Poor Control (<9%) & DM-7 (NQF 0055): Diabetes: Eye Exam ", "nationalQualityStrategyDomain": "ECC", "measureType": "intermediateOutcomeAndProcess", "measureId": "dmComposite", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0055 & 0059", "isInverse": false, "strata": [ { "description": "Percentage of patients 18 - 75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period and who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal or dilated eye exam (no evidence of retinopathy) in the 12 months prior to the measurement period", "name": "A1c>9.0%" } ], "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "cmsWebInterface" ], "measureSets": [] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "ACI_PHCDRR_5", "title": "Clinical Data Registry Reporting", "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry. Earn a 5 % bonus in the advancing care information performance category score for submitting to one or more public health or clinical data registries.", "isRequired": false, "weight": 5, "measureSets": [], "isBonus": true, "objective": "publicHealthAndClinicalDataRegistryReporting", "reportingCategory": "registryBonus", "substitutes": [ "ACI_TRANS_PHCDRR_3" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "ACI_HIE_3", "title": "Clinical Information Reconciliation", "description": "For at least one transition of care or referral received or patient encounter in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician performs clinical information reconciliation. The MIPS eligible clinician must implement clinical information reconciliation for the following three clinical information sets: (1) Medication. Review of the patient's medication, including the name, dosage, frequency, and route of each medication. (2) Medication allergy. Review of the patient's known medication allergies. (3) Current Problem list. Review of the patient's current and active diagnoses.", "isRequired": false, "weight": 10, "measureSets": [], "isBonus": false, "objective": "healthInformationExchange", "reportingCategory": "performanceBonus", "substitutes": [ "ACI_TRANS_MR_1" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "ACI_PHCDRR_3", "title": "Electronic Case Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions. Earn a 5 % bonus in the advancing care information performance category score for submitting to one or more public health or clinical data registries.", "isRequired": false, "weight": 5, "measureSets": [], "isBonus": true, "objective": "publicHealthAndClinicalDataRegistryReporting", "reportingCategory": "registryBonus", "substitutes": [] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "ACI_EP_1", "title": "e-Prescribing", "description": "At least one permissible prescription written by the MIPS eligible clinician is queried for a drug formulary and transmitted electronically using certified EHR technology.", "isRequired": true, "weight": 0, "measureSets": [], "isBonus": false, "objective": "electronicPrescribing", "reportingCategory": "base", "substitutes": [ "ACI_LVPP_1", "ACI_TRANS_EP_1", "ACI_TRANS_LVPP_1" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "ACI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", "isRequired": false, "weight": 10, "measureSets": [], "isBonus": false, "objective": "publicHealthAndClinicalDataRegistryReporting", "reportingCategory": "performanceBonus", "substitutes": [ "ACI_TRANS_PHCDRR_1" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "ACI_CCTPE_3", "title": "Patient-Generated Health Data", "description": "Patient-generated health data or data from a non-clinical setting is incorporated into the certified EHR technology for at least one unique patient seen by the MIPS eligible clinician during the performance period.", "isRequired": false, "weight": 10, "measureSets": [], "isBonus": false, "objective": "coordinationOfCareThroughPatientEngagement", "reportingCategory": "performanceBonus", "substitutes": [] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "ACI_PEA_2", "title": "Patient-Specific Education", "description": "The MIPS eligible clinician must use clinically relevant information from certified EHR technology to identify patient-specific educational resources and provide electronic access to those materials to at least one unique patient seen by the MIPS eligible clinician.", "isRequired": false, "weight": 10, "measureSets": [], "isBonus": false, "objective": "patientElectronicAccess", "reportingCategory": "performanceBonus", "substitutes": [ "ACI_TRANS_PSE_1" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "ACI_PEA_1", "title": "Provide Patient Access", "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programing Interface (API) in the MIPS eligible clinician's certified EHR technology.", "isRequired": true, "weight": 10, "measureSets": [], "isBonus": false, "objective": "patientElectronicAccess", "reportingCategory": "base", "substitutes": [ "ACI_TRANS_PEA_1" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "ACI_PHCDRR_4", "title": "Public Health Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries. Earn a 5 % bonus in the advancing care information performance category score for submitting to one or more public health or clinical data registries.", "isRequired": false, "weight": 5, "measureSets": [], "isBonus": true, "objective": "publicHealthAndClinicalDataRegistryReporting", "reportingCategory": "registryBonus", "substitutes": [] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "ACI_HIE_2", "title": "Request/Accept Summary of Care", "description": "For at least one transition of care or referral received or patient encounter in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician receives or retrieves and incorporates into the patient's record an electronic summary of care document.", "isRequired": true, "weight": 10, "measureSets": [], "isBonus": false, "objective": "healthInformationExchange", "reportingCategory": "base", "substitutes": [ "ACI_LVITC_1", "ACI_TRANS_HIE_1", "ACI_TRANS_LVOTC_1" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "ACI_CCTPE_2", "title": "Secure Messaging", "description": "For at least one unique patient seen by the MIPS eligible clinician during the performance period, a secure message was sent using the electronic messaging function of certified EHR technology to the patient (or the patient-authorized representative), or in response to a secure message sent by the patient (or the patient-authorized representative).", "isRequired": false, "weight": 10, "measureSets": [], "isBonus": false, "objective": "coordinationOfCareThroughPatientEngagement", "reportingCategory": "performanceBonus", "substitutes": [ "ACI_TRANS_SM_1" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "ACI_PPHI_1", "title": "Security Risk Analysis", "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified EHR technology in accordance with requirements in 45 CFR164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", "isRequired": true, "weight": 0, "measureSets": [], "isBonus": false, "objective": "protectPatientHealthInformation", "reportingCategory": "base", "substitutes": [ "ACI_TRANS_PPHI_1" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "ACI_HIE_1", "title": "Send a Summary of Care", "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider-(1) creates a summary of care record using certified EHR technology; and (2) electronically exchanges the summary of care record.", "isRequired": true, "weight": 10, "measureSets": [], "isBonus": false, "objective": "healthInformationExchange", "reportingCategory": "base", "substitutes": [ "ACI_LVOTC_1", "ACI_TRANS_HIE_1", "ACI_TRANS_LVOTC_1" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "ACI_PHCDRR_2", "title": "Syndromic Surveillance Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from a urgent care ambulatory setting where the jurisdiction accepts syndromic data from such settings and the standards are clearly defined. Earn a 5 % bonus in the advancing care information performance category score for submitting to one or more public health or clinical data registries.", "isRequired": false, "weight": 5, "measureSets": [], "isBonus": true, "objective": "publicHealthAndClinicalDataRegistryReporting", "reportingCategory": "registryBonus", "substitutes": [ "ACI_TRANS_PHCDRR_2" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "ACI_CCTPE_1", "title": "View, Download and Transmit (VDT)", "description": "During the performance period, at least one unique patient (or patient-authorized representatives) seen by the MIPS eligible clinician actively engages with the EHR made accessible by the MIPS eligible clinician. An MIPS eligible clinician may meet the measure by either-(1) view, download or transmit to a third party their health information; or (2) access their health information through the use of an API that can be used by applications chosen by the patient and configured to the API in the MIPS eligible clinician's certified EHR technology; or (3) a combination of (1) and (2).", "isRequired": false, "weight": 10, "measureSets": [], "isBonus": false, "objective": "coordinationOfCareThroughPatientEngagement", "reportingCategory": "performanceBonus", "substitutes": [ "ACI_TRANS_PEA_2" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "ACI_TRANS_EP_1", "title": "e-Prescribing", "description": "At least one permissible prescription written by the MIPS eligible clinician is queried for a drug formulary and transmitted electronically using certified EHR technology.", "isRequired": true, "weight": 0, "measureSets": [ "transition" ], "isBonus": false, "objective": "electronicPrescribing", "reportingCategory": "base", "substitutes": [ "ACI_TRANS_LVPP_1", "ACI_LVPP_1", "ACI_EP_1" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "ACI_TRANS_HIE_1", "title": "Health Information Exchange", "description": "The MIPS eligible clinician that transitions or refers their patient to another setting of care or health care clinician (1) uses CEHRT to create a summary of care record; and (2) electronically transmits such summary to a receiving health care clinician for at least one transition of care or referral.", "isRequired": true, "weight": 20, "measureSets": [ "transition" ], "isBonus": false, "objective": "healthInformationExchange", "reportingCategory": "base", "substitutes": [ "ACI_TRANS_LVOTC_1", "ACI_HIE_1", "ACI_LVOTC_1", "ACI_HIE_2", "ACI_LVITC_1" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "ACI_TRANS_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data.", "isRequired": false, "weight": 10, "measureSets": [ "transition" ], "isBonus": false, "objective": "publicHealthReporting", "reportingCategory": "performanceBonus", "substitutes": [ "ACI_PHCDRR_1" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "ACI_TRANS_MR_1", "title": "Medication Reconciliation", "description": "The MIPS eligible clinician performs medication reconciliation for at least one transition of care in which the patient is transitioned into the care of the MIPS eligible clinician.", "isRequired": false, "weight": 10, "measureSets": [ "transition" ], "isBonus": false, "objective": "medicationReconciliation", "reportingCategory": "performanceBonus", "substitutes": [ "ACI_HIE_3" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "ACI_TRANS_PSE_1", "title": "Patient-Specific Education", "description": "The MIPS eligible clinician must use clinically relevant information from CEHRT to identify patient-specific educational resources and provide access to those materials to at least one unique patient seen by the MIPS eligible clinician.", "isRequired": false, "weight": 10, "measureSets": [ "transition" ], "isBonus": false, "objective": "patientSpecificEducation", "reportingCategory": "performanceBonus", "substitutes": [ "ACI_PEA_2" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "ACI_TRANS_PEA_1", "title": "Provide Patient Access", "description": "At least one patient seen by the MIPS eligible clinician during the performance period is provided timely access to view online, download, and transmit to a third party their health information subject to the MIPS eligible clinician's discretion to withhold certain information.", "isRequired": true, "weight": 20, "measureSets": [ "transition" ], "isBonus": false, "objective": "patientElectronicAccess", "reportingCategory": "base", "substitutes": [ "ACI_PEA_1" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "ACI_TRANS_SM_1", "title": "Secure Messaging", "description": "For at least one unique patient seen by the MIPS eligible clinician during the performance period, a secure message was sent using the electronic messaging function of CEHRT to the patient (or the patient-authorized representative), or in response to a secure message sent by the patient (or the patient-authorized representative) during the performance period.", "isRequired": false, "weight": 10, "measureSets": [ "transition" ], "isBonus": false, "objective": "secureMessaging", "reportingCategory": "performanceBonus", "substitutes": [ "ACI_CCTPE_2" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "ACI_TRANS_PPHI_1", "title": "Security Risk Analysis", "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified EHR technology in accordance with requirements in 45 CFR164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", "isRequired": true, "weight": 0, "measureSets": [ "transition" ], "isBonus": false, "objective": "protectPatientHealthInformation", "reportingCategory": "base", "substitutes": [ "ACI_PPHI_1" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "ACI_TRANS_PHCDRR_3", "title": "Specialized Registry Reporting", "description": "The MIPS eligible clinician is in active engagement to submit data to specialized registry. Earn a 5 % bonus in the advancing care information performance category score for submitting to one or more public health or clinical data registries.", "isRequired": false, "weight": 5, "measureSets": [ "transition" ], "isBonus": true, "objective": "publicHealthReporting", "reportingCategory": "registryBonus", "substitutes": [ "ACI_PHCDRR_5" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "ACI_TRANS_PHCDRR_2", "title": "Syndromic Surveillance Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data. Earn a 5 % bonus in the advancing care information performance category score for submitting to one or more public health or clinical data registries.", "isRequired": false, "weight": 5, "measureSets": [ "transition" ], "isBonus": true, "objective": "publicHealthReporting", "reportingCategory": "registryBonus", "substitutes": [ "ACI_PHCDRR_2" ] }, { "category": "aci", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "proportion", "measureId": "ACI_TRANS_PEA_2", "title": "View, Download, or Transmit (VDT)", "description": "At least one patient seen by the MIPS eligible clinician during the performance period (or patient-authorized representative) views, downloads or transmits their health information to a third party during the performance period.", "isRequired": false, "weight": 10, "measureSets": [ "transition" ], "isBonus": false, "objective": "patientElectronicAccess", "reportingCategory": "performanceBonus", "substitutes": [ "ACI_CCTPE_1" ] }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_EPA_4", "cehrtEligible": false, "description": "As a result of Quality Innovation Network-Quality Improvement Organization technical assistance, performance of additional activities that improve access to services (e.g., investment of on-site diabetes educator).", "title": "Additional improvements in access as a result of QIN/QIO TA", "weight": "medium", "subcategoryId": "expandedPracticeAccess" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PSPA_4", "cehrtEligible": false, "description": "Administration of the AHRQ Survey of Patient Safety Culture and submission of data to the comparative database (refer to AHRQ Survey of Patient Safety Culture website http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html)", "title": "Administration of the AHRQ Survey of Patient Safety Culture", "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PSPA_5", "cehrtEligible": false, "description": "Annual registration by eligible clinician or group in the prescription drug monitoring program of the state where they practice. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and groups must participate for a minimum of 6 months.", "title": "Annual registration in the Prescription Drug Monitoring Program", "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PM_2", "cehrtEligible": true, "description": "MIPS eligible clinicians and groups who prescribe oral Vitamin K antagonist therapy (warfarin) must attest that, in the first performance year, 60 percent or more of their ambulatory care patients receiving warfarin are being managed by one or more of these clinical practice improvement activities: \nPatients are being managed by an anticoagulant management service, that involves systematic and coordinated care*, incorporating comprehensive patient education, systematic INR testing, tracking, follow-up, and patient communication of results and dosing decisions;\n\nPatients are being managed according to validated electronic decision support and clinical management tools that involve systematic and coordinated care, incorporating comprehensive patient education, systematic INR testing, tracking, follow-up, and patient communication of results and dosing decisions;\n\nFor rural or remote patients, patients are managed using remote monitoring or telehealth options that involve systematic and coordinated care, incorporating comprehensive patient education, systematic INR testing, tracking, follow-up, and patient communication of results and dosing decisions; and/or\n\nFor patients who demonstrate motivation, competency, and adherence, patients are managed using either a patient self-testing (PST) or patient-self-management (PSM) program.\n\nThe performance threshold will increase to 75 percent for the second performance year and onward.\nClinicians would attest that, 60 percent for first year, or 75 percent for the second year, of their ambulatory care patients receiving warfarin participated in an anticoagulation management program for at least 90 days during the performance period.\n\n\n", "title": "Anticoagulant management improvements", "weight": "high", "subcategoryId": "populationManagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_CC_12", "cehrtEligible": false, "description": "Establish effective care coordination and active referral management that could include one or more of the following:\n\nEstablish care coordination agreements with frequently used consultants that set expectations for documented flow of information and MIPS eligible clinician or MIPS eligible clinician group expectations between settings. Provide patients with information that sets their expectations consistently with the care coordination agreements;\n\nTrack patients referred to specialist through the entire process; and/or\nSystematically integrate information from referrals into the plan of care.\n\n", "title": "Care coordination agreements that promote improvements in patient tracking across settings", "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_CC_10", "cehrtEligible": false, "description": "Implementation of practices/processes for care transition that include documentation of how a MIPS eligible clinician or group carried out a patient-centered action plan for first 30 days following a discharge (e.g., staff involved, phone calls conducted in support of transition, accompaniments, navigation actions, home visits, patient information access, etc.).", "title": "Care transition documentation practice improvements", "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_CC_11", "cehrtEligible": false, "description": "Establish standard operations to manage transitions of care that could include one or more of the following: \n\nEstablish formalized lines of communication with local settings in which empaneled patients receive care to ensure documented flow of information and seamless transitions in care; and/or\n\nPartner with community or hospital-based transitional care services.\n", "title": "Care transition standard operational improvements", "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PM_13", "cehrtEligible": true, "description": "Proactively manage chronic and preventive care for empaneled patients that could include one or more of the following: \nProvide patients annually with an opportunity for development and/or adjustment of an individualized plan of care as appropriate to age and health status, including health risk appraisal; gender, age and condition-specific preventive care services; plan of care for chronic conditions; and advance care planning;\nUse condition-specific pathways for care of chronic conditions (e.g., hypertension, diabetes, depression, asthma and heart failure) with evidence-based protocols to guide treatment to target;\nUse pre-visit planning to optimize preventive care and team management of patients with chronic conditions;\nUse panel support tools (registry functionality) to identify services due; \nUse reminders and outreach (e.g., phone calls, emails, postcards, patient portals and community health workers where available) to alert and educate patients about services due; and/or\nRoutine medication reconciliation.", "title": "Chronic care and preventative care management for empanelled patients", "weight": "medium", "subcategoryId": "populationManagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_CC_5", "cehrtEligible": false, "description": "Membership and participation in a CMS Partnership for Patients Hospital Improvement Innovation Network.", "title": "CMS partner in Patients Hospital Improvement Innovation Networks", "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BE_6", "cehrtEligible": false, "description": "Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of improvement plan. ", "title": "Collection and follow-up on patient experience and satisfaction data on beneficiary engagement", "weight": "high", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_EPA_3", "cehrtEligible": false, "description": "Collection of patient experience and satisfaction data on access to care and development of an improvement plan, such as outlining steps for improving communications with patients to help understanding of urgent access needs. ", "title": "Collection and use of patient experience and satisfaction data on access", "weight": "medium", "subcategoryId": "expandedPracticeAccess" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PSPA_9", "cehrtEligible": false, "description": "Completion of the American Medical Association's STEPS Forward program.", "title": "Completion of the AMA STEPS Forward program", "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PSPA_10", "cehrtEligible": false, "description": "Completion of training and obtaining an approved waiver for provision of medication-assisted treatment of opioid use disorders using buprenorphine.", "title": "Completion of training and receipt of approved waiver for provision opioid medication-assisted treatments", "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PSPA_6", "cehrtEligible": false, "description": "Clinicians would attest that, 60 percent for first year, or 75 percent for the second year, of consultation of prescription drug monitoring program prior to the issuance of a Controlled Substance Schedule II (CSII) opioid prescription that lasts for longer than 3 days. ", "title": "Consultation of the Prescription Drug Monitoring program", "weight": "high", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BMH_4", "cehrtEligible": false, "description": "Depression screening and follow-up plan: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including depression screening and follow-up plan (refer to NQF #0418) for patients with co-occurring conditions of behavioral or mental health conditions.", "title": "Depression screening", "weight": "medium", "subcategoryId": "behavioralAndMentalHealth" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BMH_1", "cehrtEligible": false, "description": "Diabetes screening for people with schizophrenia or bipolar disease who are using antipsychotic medication.", "title": "Diabetes screening ", "weight": "medium", "subcategoryId": "behavioralAndMentalHealth" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BMH_8", "cehrtEligible": true, "description": "Enhancements to an electronic health record to capture additional data on behavioral health (BH) populations and use that data for additional decision-making purposes (e.g., capture of additional BH data results in additional depression screening for at-risk patient not previously identified).", "title": "Electronic Health Record Enhancements for BH data capture", "weight": "medium", "subcategoryId": "behavioralAndMentalHealth" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PM_5", "cehrtEligible": false, "description": "Take steps to improve health status of communities, such as collaborating with key partners and stakeholders to implement evidenced-based practices to improve a specific chronic condition. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist MIPS eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund. ", "title": "Engagement of community for health status improvement", "weight": "medium", "subcategoryId": "populationManagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_AHE_1", "cehrtEligible": false, "description": "Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare. ", "title": "Engagement of new Medicaid patients and follow-up", "weight": "high", "subcategoryId": "achievingHealthEquity" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BE_15", "cehrtEligible": true, "description": "Engage patients, family and caregivers in developing a plan of care and prioritizing their goals for action, documented in the certified EHR technology.", "title": "Engagement of patients, family and caregivers in developing a plan of care ", "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BE_4", "cehrtEligible": true, "description": "Access to an enhanced patient portal that provides up to date information related to relevant chronic disease health or blood pressure control, and includes interactive features allowing patients to enter health information and/or enables bidirectional communication about medication changes and adherence.", "title": "Engagement of patients through implementation of improvements in patient portal", "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BE_3", "cehrtEligible": false, "description": "Engagement with a Quality Innovation Network-Quality Improvement Organization, which may include participation in self-management training programs such as diabetes.", "title": "Engagement with QIN-QIO to implement self-management training programs", "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BE_14", "cehrtEligible": false, "description": "Engage patients and families to guide improvement in the system of care.", "title": "Engage patients and families to guide improvement in the system of care.", "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BE_5", "cehrtEligible": false, "description": "Enhancements and ongoing regular updates and use of websites/tools that include consideration for compliance with section 508 of the Rehabilitation Act of 1973 or for improved design for patients with cognitive disabilities. Refer to the CMS website on Section 508 of the Rehabilitation Act https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/Section508/index.html?redirect=/InfoTechGenInfo/07_Section508.asp that requires that institutions receiving federal funds solicit, procure, maintain and use all electronic and information technology (EIT) so that equal or alternate/comparable access is given to members of the public with and without disabilities. For example, this includes designing a patient portal or website that is compliant with section 508 of the Rehabilitation Act of 1973", "title": "Enhancements/regular updates to practice websites/tools that also include considerations for patients with cognitive disabilities", "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BE_16", "cehrtEligible": false, "description": "Incorporate evidence-based techniques to promote self-management into usual care, using techniques such as goal setting with structured follow-up, Teach Back, action planning or motivational interviewing.", "title": "Evidenced-based techniques to promote self-management into usual care", "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PM_4", "cehrtEligible": true, "description": "For outpatient Medicare beneficiaries with diabetes and who are prescribed antidiabetic agents (e.g., insulin, sulfonylureas), MIPS eligible clinicians and groups must attest to having:\nFor the first performance year, at least 60 percent of medical records with documentation of an individualized glycemic treatment goal that:\na) Takes into account patient-specific factors, including, at least 1) age, 2) comorbidities, and 3) risk for hypoglycemia, and\nb) Is reassessed at least annually.\n\nThe performance threshold will increase to 75 percent for the second performance year and onward.\nClinician would attest that, 60 percent for first year, or 75 percent for the second year, of their medical records that document individualized glycemic treatment represent patients who are being treated for at least 90 days during the performance period.\n\n", "title": "Glycemic management services", "weight": "high", "subcategoryId": "populationManagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_CC_3", "cehrtEligible": false, "description": "Implementation of at least one additional recommended activity from the Quality Innovation Network-Quality Improvement Organization after technical assistance has been provided related to improving care coordination.", "title": "Implementation of additional activity as a result of TA for improving care coordination", "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PSPA_17", "cehrtEligible": false, "description": "Build the analytic capability required to manage total cost of care for the practice population that could include one or more of the following:\n\nTrain appropriate staff on interpretation of cost and utilization information; and/or\n\nUse available data regularly to analyze opportunities to reduce cost through improved care.\n", "title": "Implementation of analytic capabilities to manage total cost of care for practice population", "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PSPA_15", "cehrtEligible": false, "description": "Implementation of an antibiotic stewardship program that measures the appropriate use of antibiotics for several different conditions (URI Rx in children, diagnosis of pharyngitis, Bronchitis Rx in adults) according to clinical guidelines for diagnostics and therapeutics", "title": "Implementation of antibiotic stewardship program", "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BMH_6", "cehrtEligible": false, "description": "Integration facilitation, and promotion of the colocation of mental health services in primary and/or non-primary clinical care settings.", "title": "Implementation of co-location PCP and MH services", "weight": "high", "subcategoryId": "behavioralAndMentalHealth" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BE_20", "cehrtEligible": false, "description": "Provide condition-specific chronic disease self-management support programs or coaching or link patients to those programs in the community.", "title": "Implementation of condition-specific chronic disease self-management support programs", "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_CC_8", "cehrtEligible": true, "description": "Implementation of practices/processes that document care coordination activities (e.g., a documented care coordination encounter that tracks all clinical staff involved and communications from date patient is scheduled for outpatient procedure through day of procedure).", "title": "Implementation of documentation improvements for practice/process improvements", "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PM_15", "cehrtEligible": true, "description": "Provide episodic care management, including management across transitions and referrals that could include one or more of the following:\nRoutine and timely follow-up to hospitalizations, ED visits and stays in other institutional settings, including symptom and disease management, and medication reconciliation and management; and/or\nManaging care intensively through new diagnoses, injuries and exacerbations of illness.\n", "title": "Implementation of episodic care management practice improvements", "weight": "medium", "subcategoryId": "populationManagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PSPA_21", "cehrtEligible": false, "description": "Implementation of fall screening and assessment programs to identify patients at risk for falls and address modifiable risk factors (e.g., Clinical decision support/prompts in the electronic health record that help manage the use of medications, such as benzodiazepines, that increase fall risk).", "title": "Implementation of fall screening and assessment programs", "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PSPA_19", "cehrtEligible": false, "description": "Adopt a formal model for quality improvement and create a culture in which all staff actively participates in improvement activities that could include one or more of the following: \nTrain all staff in quality improvement methods; \nIntegrate practice change/quality improvement into staff duties;\nEngage all staff in identifying and testing practices changes;\nDesignate regular team meetings to review data and plan improvement cycles;\nPromote transparency and accelerate improvement by sharing practice level and panel level quality of care, patient experience and utilization data with staff; and/or\nPromote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families.\n", "title": "Implementation of formal quality improvement methods, practice changes or other practice improvement processes", "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_CC_2", "cehrtEligible": false, "description": "Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.", "title": "Implementation of improvements that contribute to more timely communication of test results", "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BMH_7", "cehrtEligible": true, "description": "Offer integrated behavioral health services to support patients with behavioral health needs, dementia, and poorly controlled chronic conditions that could include one or more of the following:\nUse evidence-based treatment protocols and treatment to goal where appropriate;\nUse evidence-based screening and case finding strategies to identify individuals at risk and in need of services;\nEnsure regular communication and coordinated workflows between eligible clinicians in primary care and behavioral health;\nConduct regular case reviews for at-risk or unstable patients and those who are not responding to treatment;\nUse of a registry or certified health information technology functionality to support active care management and outreach to patients in treatment; and/or\nIntegrate behavioral health and medical care plans and facilitate integration through co-location of services when feasible.\n", "title": "Implementation of integrated PCBH model", "weight": "high", "subcategoryId": "behavioralAndMentalHealth" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PM_16", "cehrtEligible": true, "description": "Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: \nReconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; \nIntegrate a pharmacist into the care team; and/or\nConduct periodic, structured medication reviews.\n", "title": "Implementation of medication management practice improvements", "weight": "medium", "subcategoryId": "populationManagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PM_14", "cehrtEligible": true, "description": "Provide longitudinal care management to patients at high risk for adverse health outcome or harm that could include one or more of the following:\nUse a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts. Monitor the risk-stratification method and refine as necessary to improve accuracy of risk status identification;\nUse a personalized plan of care for patients at high risk for adverse health outcome or harm, integrating patient goals, values and priorities; and/or\nUse on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients.\n", "title": "Implementation of methodologies for improvements in longitudinal care management for high risk patients", "weight": "medium", "subcategoryId": "populationManagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_CC_9", "cehrtEligible": true, "description": "Implementation of practices/processes to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s). ", "title": "Implementation of practices/processes for developing regular individual care plans", "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_CC_1", "cehrtEligible": true, "description": "Performance of regular practices that include providing specialist reports back to the referring MIPS eligible clinician or group to close the referral loop or where the referring MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the certified EHR technology.", "title": "Implementation of use of specialist reports back to referring clinician or group to close referral loop", "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BE_21", "cehrtEligible": false, "description": "Provide self-management materials at an appropriate literacy level and in an appropriate language.", "title": "Improved practices that disseminate appropriate self-management materials", "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BE_22", "cehrtEligible": false, "description": "Provide a pre-visit development of a shared visit agenda with the patient.", "title": "Improved practices that engage patients pre-visit", "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BE_23", "cehrtEligible": false, "description": "Provide coaching between visits with follow-up on care plan and goals.", "title": "Integration of patient coaching practices between visits", "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PSPA_20", "cehrtEligible": false, "description": "Ensure full engagement of clinical and administrative leadership in practice improvement that could include one or more of the following: \n\nMake responsibility for guidance of practice change a component of clinical and administrative leadership roles; \n\nAllocate time for clinical and administrative leadership for practice improvement efforts, including participation in regular team meetings; and/or\n\nIncorporate population health, quality and patient experience metrics in regular reviews of practice performance.\n", "title": "Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes", "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_AHE_4", "cehrtEligible": false, "description": "Participation in a QCDR, demonstrating performance of activities for use of standard questionnaires for assessing improvements in health disparities related to functional health status (e.g., use of Seattle Angina Questionnaire, MD Anderson Symptom Inventory, and/or SF-12/VR-12 functional health status assessment).", "title": "Leveraging a QCDR for use of standard questionnaires", "weight": "medium", "subcategoryId": "achievingHealthEquity" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_AHE_3", "cehrtEligible": false, "description": "Participation in a QCDR, demonstrating performance of activities for promoting use of patient-reported outcome (PRO) tools and corresponding collection of PRO data (e.g., use of PQH-2 or PHQ-9 and PROMIS instruments).", "title": "Leveraging a QCDR to promote use of patient-reported outcome tools", "weight": "medium", "subcategoryId": "achievingHealthEquity" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_AHE_2", "cehrtEligible": true, "description": "Participation in a QCDR, demonstrating performance of activities for use of standardized processes for screening for social determinants of health such as food security, employment and housing. Use of supporting tools that can be incorporated into the certified EHR technology is also suggested.", "title": "Leveraging a QCDR to standardize processes for screening", "weight": "medium", "subcategoryId": "achievingHealthEquity" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BMH_5", "cehrtEligible": false, "description": "Major depressive disorder: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including suicide risk assessment (refer to NQF #0104) for mental health patients with co-occurring conditions of behavioral or mental health conditions. ", "title": "MDD prevention and treatment interventions", "weight": "medium", "subcategoryId": "behavioralAndMentalHealth" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PSPA_18", "cehrtEligible": false, "description": "Measure and improve quality at the practice and panel level that could include one or more of the following:\n\nRegularly review measures of quality, utilization, patient satisfaction and other measures that may be useful at the practice level and at the level of the care team or MIPS eligible clinician or group(panel); and/or\nUse relevant data sources to create benchmarks and goals for performance at the practice level and panel level.\n\n", "title": "Measurement and improvement at the practice and panel level", "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PSPA_3", "cehrtEligible": false, "description": "For eligible professionals not participating in Maintenance of Certification (MOC) Part IV, new engagement for MOC Part IV, such as IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS(R)", "title": "Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS(R) or other similar activity.", "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_ERP_2", "cehrtEligible": false, "description": "Participation in domestic or international humanitarian volunteer work. Activities that simply involve registration are not sufficient. MIPS eligible clinicians attest to domestic or international humanitarian volunteer work for a period of a continuous 60 days or greater.", "title": "Participation in a 60-day or greater effort to support domestic or international humanitarian needs.", "weight": "high", "subcategoryId": "emergencyResponseAndPreparedness" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PSPA_1", "cehrtEligible": false, "description": "Participation in an AHRQ-listed patient safety organization. ", "title": "Participation in an AHRQ-listed patient safety organization. ", "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BE_8", "cehrtEligible": false, "description": "Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive. ", "title": "Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive. ", "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BE_10", "cehrtEligible": false, "description": "Participation in a QCDR, that promotes implementation of patient self-action plans. ", "title": "Participation in a QCDR, that promotes implementation of patient self-action plans. ", "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BE_7", "cehrtEligible": false, "description": "Participation in a QCDR, that promotes use of patient engagement tools. ", "title": "Participation in a QCDR, that promotes use of patient engagement tools. ", "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BE_11", "cehrtEligible": false, "description": "Participation in a QCDR, that promotes use of processes and tools that engage patients for adherence to treatment plan. ", "title": "Participation in a QCDR, that promotes use of processes and tools that engage patients for adherence to treatment plan. ", "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PSPA_14", "cehrtEligible": false, "description": "Participation in other quality improvement programs such as Bridges to Excellence", "title": "Participation in Bridges to Excellence or other similar program", "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PSPA_11", "cehrtEligible": false, "description": "Participation in the Consumer Assessment of Healthcare Providers and Systems Survey or other supplemental questionnaire items (e.g., Cultural Competence or Health Information Technology supplemental item sets).", "title": "Participation in CAHPS or other supplemental questionnaire", "weight": "high", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PM_8", "cehrtEligible": false, "description": " Participation in CMMI models such as the Million Hearts Cardiovascular Risk Reduction Model", "title": "Participation in CMMI models such as Million Hearts Campaign", "weight": "medium", "subcategoryId": "populationManagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PSPA_13", "cehrtEligible": false, "description": "Participation in Joint Commission Ongoing Professional Practice Evaluation initiative", "title": "Participation in Joint Commission Evaluation Initiative", "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PSPA_2", "cehrtEligible": false, "description": "Participation in Maintenance of Certification (MOC) Part IV for improving professional practice including participation in a local, regional or national outcomes registry or quality assessment program. Performance of monthly activities across practice to regularly assess performance in practice, by reviewing outcomes addressing identified areas for improvement and evaluating the results.", "title": "Participation in MOC Part IV", "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PM_9", "cehrtEligible": false, "description": "Participation in research that identifies interventions, tools or processes that can improve a targeted patient population.", "title": "Participation in population health research", "weight": "medium", "subcategoryId": "populationManagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PSPA_12", "cehrtEligible": false, "description": "Participation in designated private payer clinical practice improvement activities.", "title": "Participation in private payer CPIA", "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PM_1", "cehrtEligible": false, "description": " Participation in a systematic anticoagulation program (coagulation clinic, patient self-reporting program, patient self-management program)for 60 percent of practice patients in year 1 and 75 percent of practice patients in year 2 who receive anti-coagulation medications (warfarin or other coagulation cascade inhibitors). ", "title": "Participation in systematic anticoagulation program", "weight": "high", "subcategoryId": "populationManagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_ERP_1", "cehrtEligible": false, "description": "Participation in Disaster Medical Assistance Teams, or Community Emergency Responder Teams. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and MIPS eligible clinician groups must be registered for a minimum of 6 months as a volunteer for disaster or emergency response.", "title": "Participation on Disaster Medical Assistance Team, registered for 6 months.", "weight": "medium", "subcategoryId": "emergencyResponseAndPreparedness" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PM_12", "cehrtEligible": false, "description": "Empanel (assign responsibility for) the total population, linking each patient to a MIPS eligible clinician or group or care team.\n\nEmpanelment is a series of processes that assign each active patient to a MIPS eligible clinician or group and/or care team, confirm assignment with patients and clinicians, and use the resultant patient panels as a foundation for individual patient and population health management. \n\nEmpanelment identifies the patients and population for whom the MIPS eligible clinician or group and/or care team is responsible and is the foundation for the relationship continuity between patient and MIPS eligible clinician or group /care team that is at the heart of comprehensive primary care. Effective empanelment requires identification of the \"active population\" of the practice: those patients who identify and use your practice as a source for primary care. There are many ways to define \"active patients\" operationally, but generally, the definition of \"active patients\" includes patients who have sought care within the last 24 to 36 months, allowing inclusion of younger patients who have minimal acute or preventive health care.", "title": "Population empanelment", "weight": "medium", "subcategoryId": "populationManagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_CC_13", "cehrtEligible": true, "description": "Ensure that there is bilateral exchange of necessary patient information to guide patient care that could include one or more of the following: \n\nParticipate in a Health Information Exchange if available; and/or\n\nUse structured referral notes.\n", "title": "Practice improvements for bilateral exchange of patient information", "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_CC_14", "cehrtEligible": false, "description": "Develop pathways to neighborhood/community-based resources to support patient health goals that could include one or more of the following: \n\nMaintain formal (referral) links to community-based chronic disease self-management support programs, exercise programs and other wellness resources with the potential for bidirectional flow of information; and/or\n\nProvide a guide to available community resources.\n", "title": "Practice improvements that engage community resources to support patient health goals", "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_EPA_1", "cehrtEligible": true, "description": "Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent and emergent care (e.g., eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:\nExpanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);\n\nUse of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or\n\nProvision of same-day or next-day access to a consistent MIPS eligible clinician, group or care team when needed for urgent care or transition management\n\n", "title": "Provide 24/7 access to eligible clinicians or groups who have real-time access to patient's medical record", "weight": "high", "subcategoryId": "expandedPracticeAccess" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BE_18", "cehrtEligible": false, "description": "Provide peer-led support for self-management.", "title": "Provide peer-led support for self-management.", "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BE_13", "cehrtEligible": false, "description": "Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.", "title": "Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.", "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PM_11", "cehrtEligible": false, "description": "Implementation of regular reviews of targeted patient population needs which includes access to reports that show unique characteristics of eligible professional's patient population, identification of vulnerable patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources.", "title": "Regular review practices in place on targeted patient population needs", "weight": "medium", "subcategoryId": "populationManagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_CC_7", "cehrtEligible": false, "description": "Implementation of regular care coordination training. ", "title": "Regular training in care coordination", "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PM_3", "cehrtEligible": false, "description": "Participating in a Rural Health Clinic (RHC), Indian Health Service (IHS), or Federally Qualified Health Center in ongoing engagement activities that contribute to more formal quality reporting, and that include receiving quality data back for broader quality improvement and benchmarking improvement which will ultimately benefit patients. Participation in Indian Health Service, as an improvement activity, requires MIPS eligible clinicians and groups to deliver care to federally recognized American Indian and Alaska Native populations in the U.S. and in the course of that care implement continuous clinical practice improvement including reporting data on quality of services being provided and receiving feedback to make improvements over time.", "title": "RHC, IHS or FQHC quality improvement activities", "weight": "high", "subcategoryId": "populationManagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_CC_4", "cehrtEligible": false, "description": "Participation in the CMS Transforming Clinical Practice Initiative.", "title": "TCPI participation", "weight": "high", "subcategoryId": "careCoordination" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BMH_2", "cehrtEligible": false, "description": "Tobacco use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including tobacco use screening and cessation interventions (refer to NQF #0028) for patients with co-occurring conditions of behavioral or mental health and at risk factors for tobacco dependence.", "title": "Tobacco use", "weight": "medium", "subcategoryId": "behavioralAndMentalHealth" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BMH_3", "cehrtEligible": false, "description": "Unhealthy alcohol use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including screening and brief counseling (refer to NQF #2152) for patients with co-occurring conditions of behavioral or mental health conditions. ", "title": " Unhealthy alcohol use", "weight": "medium", "subcategoryId": "behavioralAndMentalHealth" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BE_12", "cehrtEligible": false, "description": "Use evidence-based decision aids to support shared decision-making.", "title": "Use evidence-based decision aids to support shared decision-making.", "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BE_19", "cehrtEligible": false, "description": "Use group visits for common chronic conditions (e.g., diabetes).", "title": "Use group visits for common chronic conditions (e.g., diabetes).", "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BE_1", "cehrtEligible": true, "description": "In support of improving patient access, performing additional activities that enable capture of patient reported outcomes (e.g., home blood pressure, blood glucose logs, food diaries, at-risk health factors such as tobacco or alcohol use, etc.) or patient activation measures through use of certified EHR technology, containing this data in a separate queue for clinician recognition and review.", "title": "Use of certified EHR to capture patient reported outcomes", "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PSPA_16", "cehrtEligible": true, "description": "Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs.", "title": "Use of decision support and standardized treatment protocols", "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PSPA_8", "cehrtEligible": false, "description": " Use of tools that assist specialty practices in tracking specific measures that are meaningful to their practice, such as use of the Surgical Risk Calculator. ", "title": "Use of patient safety tools", "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PSPA_7", "cehrtEligible": false, "description": "Use of QCDR data, for ongoing practice assessment and improvements in patient safety. ", "title": "Use of QCDR data for ongoing practice assessment and improvements", "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PM_10", "cehrtEligible": false, "description": "Participation in a QCDR, clinical data registries, or other registries run by other government agencies such as FDA, or private entities such as a hospital or medical or surgical society. Activity must include use of QCDR data for quality improvement (e.g., comparative analysis across specific patient populations for adverse outcomes after an outpatient surgical procedure and corrective steps to address adverse outcome). ", "title": "Use of QCDR data for quality improvement such as comparative analysis reports across patient populations", "weight": "medium", "subcategoryId": "populationManagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PM_7", "cehrtEligible": false, "description": " Use of a QCDR to generate regular feedback reports that summarize local practice patterns and treatment outcomes, including for vulnerable populations.", "title": "Use of QCDR for feedback reports that incorporate population health ", "weight": "high", "subcategoryId": "populationManagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BE_9", "cehrtEligible": false, "description": " Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement. ", "title": " Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement. ", "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_CC_6", "cehrtEligible": false, "description": "Participation in a Qualified Clinical Data Registry, demonstrating performance of activities that promote use of standard practices, tools and processes for quality improvement (e.g., documented preventative screening and vaccinations that can be shared across MIPS eligible clinician or groups).", "title": "Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination", "weight": "medium", "subcategoryId": "careCoordination" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BE_2", "cehrtEligible": false, "description": "Participation in a QCDR, demonstrating performance of activities that promote implementation of shared clinical decision making capabilities.", "title": "Use of QCDR to support clinical decision making", "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_EPA_2", "cehrtEligible": false, "description": "Use of telehealth services and analysis of data for quality improvement, such as participation in remote specialty care consults or teleaudiology pilots that assess ability to still deliver quality care to patients. ", "title": "Use of telehealth services that expand practice access", "weight": "medium", "subcategoryId": "expandedPracticeAccess" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_PM_6", "cehrtEligible": false, "description": "Take steps to improve healthcare disparities, such as Population Health Toolkit or other resources identified by CMS, the Learning and Action Network, Quality Innovation Network, or National Coordinating Center. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.", "title": "Use of toolsets or other resources to close healthcare disparities across communities", "weight": "medium", "subcategoryId": "populationManagement" }, { "category": "ia", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "boolean", "measureId": "IA_BE_17", "cehrtEligible": false, "description": "Use tools to assist patients in assessing their need for support for self-management (e.g., the Patient Activation Measure or How's My Health).", "title": "Use of tools to assist patient self-management", "weight": "medium", "subcategoryId": "beneficiaryEngagement" }, { "category": "cost", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "costScore", "title": "Medicare Spending Per Beneficiary (MSPB)", "description": "The Medicare Spending Per Beneficiary (MSPB) measure evaluates solo practitioners and groups on their spending efficiency and is risk-adjusted to account for patients' risk profiles. Solo practitioners and groups are identified by their National Provider Identification (NPI) and Taxpayer Identification Number (TIN) combination. Specifically, the MSPB measure assesses the average spend for Medicare services performed by providers/groups per episode of care. Each episode comprises the period immediately prior to, during, and following a patient's hospital stay.", "measureId": "MSPB_1", "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ] }, { "category": "cost", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "costScore", "title": "Total Per Capita Costs (TPCC)", "description": "The Total Per Capita Costs (TPCC) measure is a payment-standardized, annualized, risk-adjusted, and specialty-adjusted measure that evaluates the overall efficiency of care provided to beneficiaries attributed to solo practitioners and groups, as identified by their Medicare Taxpayer Identification Number (TIN)", "measureId": "TPCC_1", "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use", "description": "Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy", "nationalQualityStrategyDomain": "ECR", "measureType": "process", "measureId": "093", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0654", "isInverse": false, "strata": [ { "description": "Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy", "name": "AOE" } ], "isHighPriority": true, "primarySteward": "American Academy of Otolaryngology-Head and Neck Surgery", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "emergencyMedicine", "otolaryngology", "generalPracticeFamilyMedicine", "pediatrics" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Acute Otitis Externa (AOE): Topical Therapy", "description": "Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "091", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0653", "isInverse": false, "strata": [ { "description": "Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations", "name": "AOE" } ], "isHighPriority": true, "primarySteward": "American Academy of Otolaryngology-Head and Neck Surgery", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "emergencyMedicine", "otolaryngology", "pediatrics" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "multiPerformanceRate", "title": "ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication", "description": "Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. \na. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase.\nb. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.\n", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "366", "eMeasureId": "CMS136v6", "nqfEMeasureId": null, "nqfId": "0108", "isInverse": false, "strata": [ { "description": "Patients who had at least one face-to-face visit with a practitioner with prescribing authority within 30 days after the IPSD.", "eMeasureUuids": { "initialPopulationUuid": "4DF80BC3-980B-465E-8591-616C7DB74FBD", "denominatorUuid": "815F709E-9703-4A6E-860F-CB0096A98B71", "numeratorUuid": "341DBA96-D1CC-409F-99D9-8AB80D03B4A8", "denominatorExclusionUuid": "FE028D3B-7AB5-418B-A90C-CCFE76F25078" }, "name": "visitWithin30Days" }, { "description": "Patients who had at least one face-to-face visit with a practitioner with prescribing authority during the Initiation Phase, and at least two follow-up visits during the Continuation and Maintenance Phase. One of the two visits during the Continuation and Maintenance Phase may be a telephone visit with a practitioner.", "eMeasureUuids": { "initialPopulationUuid": "9FC61BF5-1EBD-44DE-ADCB-64E70FD3C0A5", "denominatorUuid": "62FDAE01-000B-40A0-9C74-4A803BA37A96", "numeratorUuid": "5097B983-9C47-4F28-9194-C795F42053AF", "denominatorExclusionUuid": "425772D2-6437-4F33-9B1E-349E1C6587D9" }, "name": "visitAndFollowups" } ], "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "mentalBehavioralHealth", "pediatrics" ], "eMeasureUuid": "40280381-51f0-825b-0152-22a639d81762", "overallAlgorithm": "simpleAverage" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Adherence to Antipsychotic Medications For Individuals with Schizophrenia", "description": "Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months)", "nationalQualityStrategyDomain": "PS", "measureType": "intermediateOutcome", "measureId": "383", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1879", "isInverse": false, "strata": [ { "description": "Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months)", "name": "schizophrenia" } ], "isHighPriority": true, "primarySteward": "Health Services Advisory Group ", "submissionMethods": [ "registry" ], "measureSets": [ "mentalBehavioralHealth" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "multiPerformanceRate", "title": "Adult Kidney Disease: Blood Pressure Management", "description": "Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) with a blood pressure < 140/90 mmHg OR >= 140/90 mmHg with a documented plan of care", "nationalQualityStrategyDomain": "ECC", "measureType": "intermediateOutcome", "measureId": "122", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of patient visits with blood pressure results < 140/90 mmHg", "name": "<140/90mmHg" }, { "description": "Percentage of patient visits with blood pressure results ≥ 140/90 mmHg and plan of care", "name": "planOfCare" }, { "description": "Overall percentage of patient visits with blood pressure results < 140/90 mmHg and ≥ 140/90 mmHg with a documented plan of care Eligible clinicians should continue to report the measure as specified, with no additional steps needed to account for multiple performance rates.", "name": "overall" } ], "isHighPriority": true, "primarySteward": "Renal Physicians Association", "submissionMethods": [ "registry" ], "measureSets": [], "overallAlgorithm": "overallStratumOnly" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis", "description": "Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) who initiate maintenance hemodialysis during the measurement period, whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated", "nationalQualityStrategyDomain": "ECC", "measureType": "outcome", "measureId": "329", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) who initiate maintenance hemodialysis during the measurement period, whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated", "name": "ESRD" } ], "isHighPriority": true, "primarySteward": "Renal Physicians Association", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days", "description": "Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving maintenance hemodialysis for greater than or equal to 90 days whose mode of vascular access is a catheter", "nationalQualityStrategyDomain": "PS", "measureType": "outcome", "measureId": "330", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving maintenance hemodialysis for greater than or equal to 90 days whose mode of vascular access is a catheter", "name": "ESRD" } ], "isHighPriority": true, "primarySteward": "Renal Physicians Association", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Adult Kidney Disease: Referral to Hospice", "description": "Percentage of patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care", "nationalQualityStrategyDomain": "PCCEO", "measureType": "process", "measureId": "403", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care", "name": "ESRD" } ], "isHighPriority": true, "primarySteward": "Renal Physicians Association", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions", "description": "Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition", "nationalQualityStrategyDomain": "CCC", "measureType": "process", "measureId": "325", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition", "name": "comorbid" } ], "isHighPriority": true, "primarySteward": "American Psychiatric Association", "submissionMethods": [ "registry" ], "measureSets": [ "mentalBehavioralHealth" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Adult Major Depressive Disorder (MDD): Suicide Risk Assessment", "description": "Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "107", "eMeasureId": "CMS161v5", "nqfEMeasureId": null, "nqfId": "0104", "isInverse": false, "strata": [ { "description": "Patients with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified", "eMeasureUuids": { "initialPopulationUuid": "9CDC88D7-31DA-44F1-9348-CFDD29F4B20B", "denominatorUuid": "1EC810C4-E6D2-4ED6-AE02-A0BF4D675F05", "numeratorUuid": "693493EC-2E8E-447C-88A3-FC93AD771AB9" }, "name": "assessedSuicideRisk" } ], "isHighPriority": false, "primarySteward": "Physician Consortium for Performance Improvement", "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [], "eMeasureUuid": "40280381-503f-a1fc-0150-de8350a220c3" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery", "description": "Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery", "nationalQualityStrategyDomain": "ECC", "measureType": "outcome", "measureId": "384", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery", "name": "retinalDetachment" } ], "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology", "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery", "description": "Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye", "nationalQualityStrategyDomain": "ECC", "measureType": "outcome", "measureId": "385", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye", "name": "retinalDetachment" } ], "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology", "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse)", "description": "Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms", "nationalQualityStrategyDomain": "ECR", "measureType": "process", "measureId": "331", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": true, "strata": [ { "description": "Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms", "name": "sinusitis" } ], "isHighPriority": true, "primarySteward": "American Academy of Otolaryngology-Head and Neck Surgery", "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "internalMedicine", "otolaryngology", "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)", "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": "ECR", "measureType": "process", "measureId": "332", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "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", "name": "sinusitis" } ], "isHighPriority": true, "primarySteward": "American Academy of Otolaryngology-Head and Neck Surgery", "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "internalMedicine", "otolaryngology", "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)", "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": "ECR", "measureType": "efficiency", "measureId": "333", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": true, "strata": [ { "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", "name": "sinusitis" } ], "isHighPriority": true, "primarySteward": "American Academy of Otolaryngology-Head and Neck Surgery", "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "internalMedicine", "otolaryngology", "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse)", "description": "Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis", "nationalQualityStrategyDomain": "ECR", "measureType": "efficiency", "measureId": "334", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": true, "strata": [ { "description": "Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after date of diagnosis", "name": "sinusitis" } ], "isHighPriority": true, "primarySteward": "American Academy of Otolaryngology-Head and Neck Surgery", "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "internalMedicine", "otolaryngology", "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Age Appropriate Screening Colonoscopy", "description": "The percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31", "nationalQualityStrategyDomain": "ECR", "measureType": "efficiency", "measureId": "439", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "The percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31", "name": "colonoscopy" } ], "isHighPriority": true, "primarySteward": "American Gastroenterological Association", "submissionMethods": [ "registry" ], "measureSets": [ "gastroenterology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement", "description": "Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the Age-Related Eye Disease Study (AREDS) formulation for preventing progression of AMD", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "140", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0566", "isInverse": false, "strata": [ { "description": "Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the Age-Related Eye Disease Study (AREDS) formulation for preventing progression of AMD", "name": "AMD" } ], "isHighPriority": false, "primarySteward": "American Academy of Ophthalmology", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "ophthalmology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Age-Related Macular Degeneration (AMD): Dilated Macular Examination", "description": "Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or hemorrhage AND the level of macular degeneration severity during one or more office visits within 12 months", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "014", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0087", "isInverse": false, "strata": [ { "description": "Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or hemorrhage the level of macular degeneration severity during one or more office visits within 12 months", "name": "AMD" } ], "isHighPriority": false, "primarySteward": "American Academy of Ophthalmology", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "ophthalmology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "costScore", "title": "All-cause Hospital Readmission", "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": "CCC", "measureType": "outcome", "measureId": "458", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1789", "isInverse": true, "strata": [], "isHighPriority": false, "primarySteward": "Yale University", "submissionMethods": [ "administrativeClaims" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences", "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": "PCCEO", "measureType": "process", "measureId": "386", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "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", "name": "ALS" } ], "isHighPriority": true, "primarySteward": "American Academy of Neurology", "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Anastomotic Leak Intervention", "description": "Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery", "nationalQualityStrategyDomain": "PS", "measureType": "outcome", "measureId": "354", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery", "name": "colectomy" } ], "isHighPriority": true, "primarySteward": "American College of Surgeons", "submissionMethods": [ "registry" ], "measureSets": [ "generalSurgery" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Anesthesiology Smoking Abstinence", "description": "The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure", "nationalQualityStrategyDomain": "ECC", "measureType": "intermediateOutcome", "measureId": "404", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure", "name": "cigarettes" } ], "isHighPriority": true, "primarySteward": "American Society of Anesthesiologists", "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users", "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": "ECC", "measureType": "process", "measureId": "387", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "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", "name": "HCV" } ], "isHighPriority": false, "primarySteward": "Physician Consortium for Performance Improvement", "submissionMethods": [ "registry" ], "measureSets": [ "internalMedicine", "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "multiPerformanceRate", "title": "Anti-Depressant Medication Management", "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. Two rates are reported. \na. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks). \nb. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).\n", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "009", "eMeasureId": "CMS128v5", "nqfEMeasureId": null, "nqfId": "0105", "isInverse": false, "strata": [ { "description": "Patients who have received antidepressant medication for at least 84 days (12 weeks) of continuous treatment during the 114-day period following the Index Prescription Start Date", "eMeasureUuids": { "initialPopulationUuid": "220EBFDC-C2DF-431B-B14A-8982026B10F1", "denominatorUuid": "50E80E87-0A09-4914-8632-BD0797460B34", "numeratorUuid": "02A8409A-7B63-4FE9-B865-87C650DD7459", "denominatorExclusionUuid": "BA926F92-CA87-43B3-A5C4-FD9FF8B59BB5" }, "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": "1E041190-8EE7-46B0-A735-B416C5FA76FC", "denominatorUuid": "B1C6949E-6854-4182-8BC9-C0EE75B705A2", "numeratorUuid": "3A4FA8BB-D8BC-4F66-9367-A71DF03A868D", "denominatorExclusionUuid": "8C51C326-AE19-462B-9745-6C8ABE92AE27" }, "name": ">=180Days" } ], "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "internalMedicine", "mentalBehavioralHealth", "generalPracticeFamilyMedicine" ], "eMeasureUuid": "40280381-51f0-825b-0152-22a112d2172a", "overallAlgorithm": "simpleAverage" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal", "description": "Percentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal or the inability to contact the patient with at least two attempts", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "421", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal or the inability to contact the patient with at least two attempts", "name": "IVC" } ], "isHighPriority": false, "primarySteward": "Society of Interventional Radiology ", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Appropriate Follow-up Imaging for Incidental Abdominal Lesions", "description": "Percentage of final reports for abdominal imaging studies for asymptomatic patients aged 18 years and older with one or more of the following noted incidentally with follow-up imaging recommended:\n
", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "405", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of final reports for abdominal imaging studies for asymptomatic patients aged 18 years and older with one or more of the following noted incidentally with follow‐up imaging recommended: • Liver lesion ≤ 0.5 cm • Cystic kidney lesion < 1.0 cm • Adrenal lesion ≤ 1.0 cm", "name": "abdominalImaging" } ], "isHighPriority": true, "primarySteward": "American College of Radiology", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "diagnosticRadiology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients", "description": "Percentage of final reports for computed tomography (CT), CT angiography (CTA) or magnetic resonance imaging (MRI) or magnetic resonance angiogram (MRA) studies of the chest or neck or ultrasound of the neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "406", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of final reports for computed tomography (CT), CT angiography (CTA) or magnetic resonance imaging (MRI) or magnetic resonance angiogram (MRA) studies of the chest or neck or ultrasound of the neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended", "name": "CT" } ], "isHighPriority": true, "primarySteward": "American College of Radiology", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "diagnosticRadiology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients", "description": "Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report", "nationalQualityStrategyDomain": "CCC", "measureType": "process", "measureId": "320", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0658", "isInverse": false, "strata": [ { "description": "Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report", "name": "colonoscopy" } ], "isHighPriority": true, "primarySteward": "American Gastroenterological Association", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "gastroenterology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Appropriate Testing for Children with Pharyngitis", "description": "Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode", "nationalQualityStrategyDomain": "ECR", "measureType": "process", "measureId": "066", "eMeasureId": "CMS146v5", "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Children with a group A streptococcus test in the 7-day period from 3 days prior through 3 days after the diagnosis of pharyngitis", "name": "strep", "eMeasureUuids": { "initialPopulationUuid": "6BE37D85-960E-4C32-AD2D-FE036A058EB4", "denominatorUuid": "AE00EE88-B26B-449D-94DE-EA3887BB66E0", "numeratorUuid": "86A8B7E8-EEA2-4C19-8A1B-74B905939505", "denominatorExclusionUuid": "A0B43F8B-E6EE-4229-A05D-ECF1B601CEAF" } } ], "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "emergencyMedicine", "generalPracticeFamilyMedicine", "pediatrics" ], "eMeasureUuid": "40280381-52fc-3a32-0153-424a166015d1" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Appropriate Treatment for Children with Upper Respiratory Infection (URI)", "description": "Percentage of children 3 months-18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode", "nationalQualityStrategyDomain": "ECR", "measureType": "process", "measureId": "065", "eMeasureId": "CMS154v5", "nqfEMeasureId": null, "nqfId": "0069", "isInverse": false, "strata": [ { "description": "Children without a prescription for antibiotic medication on or 3 days after the outpatient or ED visit for an upper respiratory infection", "name": "URI", "eMeasureUuids": { "initialPopulationUuid": "A5BF87B0-15CF-4012-9E29-DC85010676BC", "denominatorUuid": "FDE4FCC5-826B-42C6-82BE-1694DD18A48D", "numeratorUuid": "27037F9E-5C8E-41FE-A973-E2E020C97DA7", "denominatorExclusionUuid": "8E32E552-A70A-4BBC-A92A-F8D3D48113CF" } } ], "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "generalPracticeFamilyMedicine", "pediatrics" ], "eMeasureUuid": "40280381-52fc-3a32-0153-42810251160f" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia", "description": "Percentage of patients with sepsis due to MSSA bacteremia who received beta-lactam antibiotic (e.g. nafcillin, oxacillin or cefazolin) as definitive therapy", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "407", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of patients with sepsis due to MSSA bacteremia who received beta-lactam antibiotic (e.g. nafcillin, oxacillin or cefazolin) as definitive therapy", "name": "MSSA" } ], "isHighPriority": true, "primarySteward": "Infectious Diseases Society of America", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "hospitalists" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Appropriate Workup Prior to Endometrial Ablation", "description": "Percentage of women, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy before undergoing an endometrial ablation", "nationalQualityStrategyDomain": "PS", "measureType": "process", "measureId": "448", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0567", "isInverse": false, "strata": [ { "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", "name": "endometrialAblation" } ], "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "submissionMethods": [ "registry" ], "measureSets": [ "obstetricsGynecology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy", "description": "Percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter whose assessment of the specified thromboembolic risk factors indicate one or more high-risk factors or more than one moderate risk factor, as determined by CHADS2 risk stratification, who are prescribed warfarin OR another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "326", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1525", "isInverse": false, "strata": [ { "description": "Percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter whose assessment of the specified thromboembolic risk factors indicate one or more high-risk factors or more than one moderate risk factor, as determined by CHADS2 risk stratification, who are prescribed warfarin another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism", "name": "AF" } ], "isHighPriority": false, "primarySteward": "American College of Cardiology", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "internalMedicine", "cardiology", "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis", "description": "The percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription", "nationalQualityStrategyDomain": "ECR", "measureType": "process", "measureId": "116", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0058", "isInverse": false, "strata": [ { "description": "The percentage of adults 18–64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription", "name": "bronchitis" } ], "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "registry" ], "measureSets": [ "internalMedicine", "emergencyMedicine", "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Barrett's Esophagus", "description": "Percentage of esophageal biopsy reports that document the presence of Barrett's mucosa that also include a statement about dysplasia", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "249", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1854", "isInverse": false, "strata": [ { "description": "Percentage of esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasia", "name": "barrettsMucosa" } ], "isHighPriority": false, "primarySteward": "College of American Pathologists", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "pathology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma: Biopsy Reporting Time - Pathologist to Clinician", "description": "Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC) (including in situ disease) in which the pathologist communicates results to the clinician within 7 days of biopsy date", "nationalQualityStrategyDomain": "CCC", "measureType": "process", "measureId": "440", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC) (including in situ disease) in which the pathologist communicates results to the clinician within 7 days of biopsy date", "name": "BCC&SCC" } ], "isHighPriority": true, "primarySteward": "American Academy of Dermatology", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Biopsy Follow-Up", "description": "Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician", "nationalQualityStrategyDomain": "CCC", "measureType": "process", "measureId": "265", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician", "name": "biopsy" } ], "isHighPriority": true, "primarySteward": "American Academy of Dermatology", "submissionMethods": [ "registry" ], "measureSets": [ "dermatology", "interventionalRadiology", "obstetricsGynecology", "urology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use", "description": "Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "367", "eMeasureId": "CMS169v5", "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Patients in the denominator with evidence of an assessment for alcohol or other substance use following or concurrent with the new diagnosis, and prior to or concurrent with the initiation of treatment for that diagnosis", "eMeasureUuids": { "initialPopulationUuid": "AB5E9E84-65FB-4566-8254-D3488CA9A169", "denominatorUuid": "9656501E-1FAB-4B81-AB59-6646F1114394", "numeratorUuid": "3C942ABF-C287-4FBB-AFEE-67BC5FC93BD0" }, "name": "substanceUse" } ], "isHighPriority": false, "primarySteward": "Center for Quality Assessment and Improvement in Mental Health", "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [], "eMeasureUuid": "40280381-503f-a1fc-0150-67942bbc07d7" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade", "description": "Percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes), and the histologic grade", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "099", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0391", "isInverse": false, "strata": [ { "description": "Percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes), and the histologic grade", "name": "pTpN" } ], "isHighPriority": false, "primarySteward": "College of American Pathologists", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "pathology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Breast Cancer Screening", "description": "Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer.", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "112", "eMeasureId": "CMS125v5", "nqfEMeasureId": null, "nqfId": "2372", "isInverse": false, "strata": [ { "description": "Women with one or more mammograms during the measurement period or the 15 months prior to the measurement period", "name": "mammogram", "eMeasureUuids": { "initialPopulationUuid": "66FD640C-70BB-400F-9926-98EA1ACEBEBA", "denominatorUuid": "40FB2D5F-7DEF-4D41-80C4-F3FBA0ED5851", "numeratorUuid": "0AB40D2B-08CE-4185-8A54-336C3140644D", "denominatorExclusionUuid": "EC5CC49E-42A7-4DD8-BD40-A6258E71DCB9" } } ], "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "claims", "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "internalMedicine", "obstetricsGynecology", "preventiveMedicine", "generalPracticeFamilyMedicine" ], "eMeasureUuid": "40280381-51f0-825b-0152-229c4ea3170c" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "cahps", "title": "CAHPS for MIPS Clinician/Group Survey", "description": "
", "nationalQualityStrategyDomain": "PCCEO", "measureType": "patientEngagementExperience", "measureId": "321", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0006 & 0005", "isInverse": false, "strata": [], "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Cardiac Rehabilitation Patient Referral from an Outpatient Setting", "description": "Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program", "nationalQualityStrategyDomain": "CCC", "measureType": "process", "measureId": "243", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0643", "isInverse": false, "strata": [ { "description": "Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program Definition: Referral - A referral is defined as an official communication between the health care provider and the patient to recommend and carry out a referral order to an outpatient CR program. This includes the provision of all necessary information to the patient that will allow the patient to enroll in an outpatient CR program. This also includes a written or electronic communication between the healthcare provider or healthcare system and the cardiac rehabilitation program that includes the patient's enrollment information for the program. A hospital discharge summary or office note may potentially be formatted to include the necessary patient information to communicate to the CR program (the patient’s cardiovascular history, testing, and treatments, for instance). According to standards of practice for cardiac rehabilitation programs, care coordination communications are sent to the referring provider, including any issues regarding treatment changes, adverse treatment responses, or new non-emergency condition (new symptoms, patient care questions, etc.) that need attention by the referring provider. These communications also include a progress report once the patient has completed the program. All communications must maintain an appropriate level of confidentiality as outlined by the 1996 Health Insurance Portability and Accountability Act (HIPAA). Note: A patient with a qualifying diagnosis should have a referral to CR within the subsequent 12 months. In the event that the patient has a second (recurrent) qualifying event before the original 12 month “referral” period has ended, a new 12 month “referral” period for CR referral starts at the time of the second qualifying event, since the patient again becomes eligible for CR at that time.", "name": "outpatient" } ], "isHighPriority": true, "primarySteward": "American College of Cardiology Foundation", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients", "description": "Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low risk surgery patients 18 years or older for preoperative evaluation during the 12-month reporting period", "nationalQualityStrategyDomain": "ECR", "measureType": "efficiency", "measureId": "322", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": true, "strata": [ { "description": "Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low risk surgery patients 18 years or older for preoperative evaluation during the 12-month reporting period", "name": "preoperative" } ], "isHighPriority": true, "primarySteward": "American College of Cardiology", "submissionMethods": [ "registry" ], "measureSets": [ "cardiology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)", "description": "Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status", "nationalQualityStrategyDomain": "ECR", "measureType": "efficiency", "measureId": "323", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": true, "strata": [ { "description": "Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status", "name": "PCI" } ], "isHighPriority": true, "primarySteward": "American College of Cardiology", "submissionMethods": [ "registry" ], "measureSets": [ "cardiology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients", "description": "Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment", "nationalQualityStrategyDomain": "ECR", "measureType": "efficiency", "measureId": "324", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": true, "strata": [ { "description": "Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment", "name": "CHD" } ], "isHighPriority": true, "primarySteward": "American College of Cardiology", "submissionMethods": [ "registry" ], "measureSets": [ "cardiology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Care Plan", "description": "Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was 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Artery Bypass Graft (CABG): Postoperative Renal Failure", "description": "Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis", "nationalQualityStrategyDomain": "ECC", "measureType": "outcome", "measureId": "167", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0114", "isInverse": true, "strata": [ { "description": "Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis", "name": "CABG" } ], "isHighPriority": true, "primarySteward": "Society of Thoracic Surgeons", "submissionMethods": [ "registry" ], "measureSets": [ "thoracicSurgery" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in 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"Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours", "nationalQualityStrategyDomain": "ECC", "measureType": "outcome", "measureId": "164", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0129", "isInverse": true, "strata": [ { "description": "Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours", "name": "CABG" } ], "isHighPriority": true, "primarySteward": "Society of Thoracic Surgeons", "submissionMethods": [ "registry" ], "measureSets": [ "thoracicSurgery" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Coronary Artery Bypass Graft (CABG): Stroke", "description": "Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have a postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused 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surgery who require a return to the operating room (OR) during the current hospitalization for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason", "nationalQualityStrategyDomain": "ECC", "measureType": "outcome", "measureId": "168", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0115", "isInverse": true, "strata": [ { "description": "Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room () during the current hospitalization for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason", "name": "CABG" } ], "isHighPriority": true, "primarySteward": "Society of Thoracic Surgeons", "submissionMethods": [ "registry" ], "measureSets": [ "thoracicSurgery" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Coronary Artery 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caregiver(s) were provided with education on dementia disease management and health behavior changes AND referred to additional resources for support within a 12 month period", "nationalQualityStrategyDomain": "CCC", "measureType": "process", "measureId": "288", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of patients, regardless of age, with a diagnosis of dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes referred to additional resources for support within a 12 month period", "name": "dementia" } ], "isHighPriority": true, "primarySteward": "American Academy of Neurology", "submissionMethods": [ "registry" ], "measureSets": [ "neurology", "mentalBehavioralHealth" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Dementia: Cognitive Assessment", "description": 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This includes diabetics who had one of the following:\r\nA retinal or dilated eye exam by an eye care professional in the measurement period or a negative retinal exam (no evidence of retinopathy) by an eye care professional in the year prior to the measurement period", "name": "diabetes", "eMeasureUuids": { "initialPopulationUuid": "321FB2D3-477E-41B7-8BB1-02EE94D08417", "denominatorUuid": "98CE7ECC-1F09-4F52-906C-E53EAB545F00", "numeratorUuid": "3F48A9B6-7B99-4BF4-AB1E-50DC1FFB9D1A" } } ], "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "claims", "cmsWebInterface", "electronicHealthRecord", "registry" ], "measureSets": [ "internalMedicine", "ophthalmology", "generalPracticeFamilyMedicine" ], "eMeasureUuid": "40280381-51f0-825b-0152-22a24cdd1740" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Diabetes: Foot Exam", "description": "The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection and sensory exam with mono filament and a pulse exam) during the measurement year", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "163", "eMeasureId": "CMS123v5", "nqfEMeasureId": null, "nqfId": "0056", "isInverse": false, "strata": [ { "description": "Patients who received visual, pulse and sensory foot examinations during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "9AB84D25-5883-4D85-A868-0D702403F250", "denominatorUuid": "61B09878-32B3-4ECB-8E78-D1093E1FDDF9", "numeratorUuid": "60EC6098-950A-40E5-994F-E9A62CFF6FC2", "denominatorExclusionUuid": "02D13BF4-EF77-4DF4-A436-834AEDBE043C" }, "name": "receivedFootExams" } ], "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "internalMedicine", "generalPracticeFamilyMedicine" ], "eMeasureUuid": "40280381-51f0-825b-0152-229b7b2f16f9" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)", "description": "Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period", "nationalQualityStrategyDomain": "ECC", "measureType": "intermediateOutcome", "measureId": "001", "eMeasureId": "CMS122v5", "nqfEMeasureId": null, "nqfId": "0059", "isInverse": true, "strata": [ { "description": "Patients whose most recent HbA1c level (performed during the measurement period) is >9.0%", "name": "A1c>9.0%", "eMeasureUuids": { "initialPopulationUuid": "0739FE2E-B8DE-4A56-B064-877CC8E0977D", "denominatorUuid": "D346DA74-F16E-4159-BEDF-331BA28837FB", "numeratorUuid": "6D01A564-58CC-4CF5-929F-B83583701BFE" } } ], "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "claims", "cmsWebInterface", "electronicHealthRecord", "registry" ], "measureSets": [ "internalMedicine", "preventiveMedicine", "generalPracticeFamilyMedicine" ], "eMeasureUuid": "40280381-51f0-825b-0152-229afff616ee" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Diabetes: Medical Attention for Nephropathy", "description": "The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period.", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "119", "eMeasureId": "CMS134v5", "nqfEMeasureId": null, "nqfId": "0062", "isInverse": false, "strata": [ { "description": "Patients with a screening for nephropathy or evidence of nephropathy during the measurement period", "name": "diabetes", "eMeasureUuids": { "initialPopulationUuid": "A27FD818-3C97-4516-A796-319B89E306AC", "denominatorUuid": "0CC16DE4-474A-4F6E-BFB8-0104709B1E05", "numeratorUuid": "5647E3D0-6550-4B0B-AE76-53CD9E99D20B" } } ], "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "generalPracticeFamilyMedicine" ], "eMeasureUuid": "40280381-528a-60ff-0152-d7504e61249a" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation", "description": "Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "126", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0417", "isInverse": false, "strata": [ { "description": "Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months", "name": "DM" } ], "isHighPriority": false, "primarySteward": "American Podiatric Medical Association", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention - Evaluation of Footwear", "description": "Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "127", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0416", "isInverse": false, "strata": [ { "description": "Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing", "name": "DM" } ], "isHighPriority": false, "primarySteward": "American Podiatric Medical Association", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care", "description": "Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months", "nationalQualityStrategyDomain": "CCC", "measureType": "process", "measureId": "019", "eMeasureId": "CMS142v5", "nqfEMeasureId": null, "nqfId": "0089", "isInverse": false, "strata": [ { "description": "Patients with documentation, at least once within 12 months, of the findings of the dilated macular or fundus exam via communication to the physician who manages the patient's diabetic care", "name": "diabeticRetinopathy", "eMeasureUuids": { "initialPopulationUuid": "2072A4E8-4486-4A10-AF97-F84ADE0EB62E", "denominatorUuid": "2BB9F18C-8E26-44D6-904E-849495A6AF90", "numeratorUuid": "BCB8AEEC-EABC-477E-AA6D-6DB34220CD85", "denominatorExceptionUuid": "608279BD-7620-4FC4-8752-08E3040BA160" } } ], "isHighPriority": true, "primarySteward": "Physician Consortium for Performance Improvement", "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "ophthalmology" ], "eMeasureUuid": "40280381-52fc-3a32-0153-1a31050d0b24" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy", "description": "Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "018", "eMeasureId": "CMS167v5", "nqfEMeasureId": null, "nqfId": "0088", "isInverse": false, "strata": [ { "description": "Patients who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy AND the presence or absence of macular edema during one or more office visits within 12 months", "eMeasureUuids": { "initialPopulationUuid": "3EB89216-BC0B-4DF7-8B8D-06B9AB68DB49", "denominatorUuid": "04507C05-46D4-4D96-9D9D-853CA557F4B2", "numeratorUuid": "3186154C-6A01-4FAF-A77F-B5233A3F078C", "denominatorExceptionUuid": "170B3877-D83D-424C-BD7E-29F644B0A6DC" }, "name": "dilatedExam12Months" } ], "isHighPriority": false, "primarySteward": "Physician Consortium for Performance Improvement", "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "ophthalmology" ], "eMeasureUuid": "40280381-52fc-3a32-0153-1a4838b80b79" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Documentation of Current Medications in the Medical Record", "description": "Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration.", "nationalQualityStrategyDomain": "PS", "measureType": "process", "measureId": "130", "eMeasureId": "CMS68v6", "nqfEMeasureId": null, "nqfId": "0419", "isInverse": false, "strata": [ { "description": "Eligible professional attests to documenting, updating or reviewing the patient's current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosages, frequency and route of administration", "name": "document", "eMeasureUuids": { "initialPopulationUuid": "D412322D-11F1-4573-893E-E6A05855DE10", "denominatorUuid": "375D0559-C749-4BB9-9267-81EDF447650B", "numeratorUuid": "EFFE261C-0D57-423E-992C-7141B132768C", "denominatorExceptionUuid": "3C100EC4-2990-4D79-AE14-E816F5E78AC8" } } ], "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "internalMedicine", "anesthesiology", "cardiology", "dermatology", "emergencyMedicine", "gastroenterology", "generalSurgery", "generalOncology", "hospitalists", "neurology", "obstetricsGynecology", "ophthalmology", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "preventiveMedicine", "rheumatology", "thoracicSurgery", "urology", "vascularSurgery", "mentalBehavioralHealth", "plasticSurgery", "generalPracticeFamilyMedicine" ], "eMeasureUuid": "40280381-52fc-3a32-0153-3d64af97147b" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Documentation of Signed Opioid Treatment Agreement", "description": "All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record.", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "412", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record", "name": "opiates" } ], "isHighPriority": false, "primarySteward": "American Academy of Neurology", "submissionMethods": [ "registry" ], "measureSets": [ "internalMedicine", "neurology", "physicalMedicine", "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Door to Puncture Time for Endovascular Stroke Treatment", "description": "Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of less than two hours", "nationalQualityStrategyDomain": "ECC", "measureType": "intermediateOutcome", "measureId": "413", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of less than two hours", "name": "stroke" } ], "isHighPriority": true, "primarySteward": "Society of Interventional Radiology ", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Elder Maltreatment Screen and Follow-Up Plan", "description": "Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen", "nationalQualityStrategyDomain": "PS", "measureType": "process", "measureId": "181", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter a documented follow-up plan on the date of the positive screen", "name": "elderMaltreament" } ], "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "internalMedicine", "mentalBehavioralHealth", "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older", "description": "Percentage of emergency department visits for patients aged 18 years and older who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT", "nationalQualityStrategyDomain": "ECR", "measureType": "efficiency", "measureId": "415", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of emergency department visits for patients aged 18 years and older who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT", "name": "headTrauma" } ], "isHighPriority": true, "primarySteward": "American College of Emergency Physicians", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "emergencyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years", "description": "Percentage of emergency department visits for patients aged 2 through 17 years who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury", "nationalQualityStrategyDomain": "ECR", "measureType": "efficiency", "measureId": "416", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of emergency department visits for patients aged 2 through 17 years who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury", "name": "headTrauma" } ], "isHighPriority": true, "primarySteward": "American College of Emergency Physicians", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "emergencyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy", "description": "All female patients of childbearing potential (12 - 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "268", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1814", "isInverse": false, "strata": [ { "description": "All female patients of childbearing potential (12 - 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception pregnancy at least once a year", "name": "epilepsy" } ], "isHighPriority": false, "primarySteward": "American Academy of Neurology", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "neurology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Evaluation or Interview for Risk of Opioid Misuse", "description": "All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "414", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record", "name": "opioidRisk" } ], "isHighPriority": false, "primarySteward": "American Academy of Neurology", "submissionMethods": [ "registry" ], "measureSets": [ "internalMedicine", "neurology", "physicalMedicine", "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Falls: Plan of Care", "description": "Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months", "nationalQualityStrategyDomain": "CCC", "measureType": "process", "measureId": "155", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0101", "isInverse": false, "strata": [ { "description": "Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months", "name": "falls" } ], "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "internalMedicine", "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Falls: Risk Assessment", "description": "Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months", "nationalQualityStrategyDomain": "PS", "measureType": "process", "measureId": "154", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0101", "isInverse": false, "strata": [ { "description": "Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months", "name": "falls" } ], "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "internalMedicine", "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Falls: Screening for Future Fall Risk", "description": "Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.", "nationalQualityStrategyDomain": "PS", "measureType": "process", "measureId": "318", "eMeasureId": "CMS139v5", "nqfEMeasureId": null, "nqfId": "0101", "isInverse": false, "strata": [ { "description": "Patients who were screened for future fall risk at least once within the measurement period", "eMeasureUuids": { "initialPopulationUuid": "0175F89E-9CD7-4CD8-8D7F-38CB825D2BDD", "denominatorUuid": "A3F77B7C-2398-470D-A359-E2A31539DF91", "numeratorUuid": "F0F4094E-CE53-44EE-8CEF-0555479E37B2", "denominatorExceptionUuid": "CF7E1913-CB4E-42F7-BAEC-0EFFF01ECB17" }, "name": "screenedForFallRisk" } ], "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [], "eMeasureUuid": "40280381-51f0-825b-0152-22aae8a21778" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "multiPerformanceRate", "title": "Follow-Up After Hospitalization for Mental Illness (FUH)", "description": "The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported:\n
", "nationalQualityStrategyDomain": "CCC", "measureType": "process", "measureId": "391", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0576", "isInverse": false, "strata": [ { "description": "The percentage of discharges for which the patient received follow-up within 30 days of discharge", "name": "30days" }, { "description": "The percentage of discharges for which the patient received follow-up within 7 days of discharge", "name": "overall" } ], "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "registry" ], "measureSets": [ "mentalBehavioralHealth", "pediatrics" ], "overallAlgorithm": "overallStratumOnly" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Functional Outcome Assessment", "description": "Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies", "nationalQualityStrategyDomain": "CCC", "measureType": "process", "measureId": "182", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2624", "isInverse": false, "strata": [ { "description": "Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies", "name": "functionalOutcome" } ], "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "physicalMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Functional Status Assessment for Total Hip Replacement", "description": "Percentage of patients 18 years of age and older with primary total hip arthroplasty (THA) who completed baseline and follow-up patient-reported functional status assessments", "nationalQualityStrategyDomain": "PCCEO", "measureType": "process", "measureId": "376", "eMeasureId": "CMS56v5", "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Patients with patient-reported functional status assessment results (eg, VR-12, VR-36,PROMIS-10-Global Health, PROMIS-29, HOOS) not more than 180 days prior to the primary THA procedure, and at least 60 days and not more than 180 days after THA procedure", "eMeasureUuids": { "initialPopulationUuid": "642D0090-BEAB-410B-B3B3-8D1A5EC5B919", "denominatorUuid": "FFA80359-2E09-48C8-8862-DD6E1F5F5428", "numeratorUuid": "7D021618-E1EE-4C2F-AD6A-F74E03D69E43", "denominatorExclusionUuid": "65458ECD-6573-4203-8C56-515063BAFE19" }, "name": "functionalStatus" } ], "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "orthopedicSurgery" ], "eMeasureUuid": "40280381-51f0-825b-0152-227617db152e" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Functional Status Assessment for Total Knee Replacement", "description": "Percentage of patients 18 years of age and older with primary total knee arthroplasty (TKA) who completed baseline and follow-up patient-reported functional status assessments", "nationalQualityStrategyDomain": "PCCEO", "measureType": "process", "measureId": "375", "eMeasureId": "CMS66v5", "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Patients with patient-reported functional status assessment results (eg, VR-12, VR-36, PROMIS-10 Global Health, PROMIS-29, KOOS) not more than 180 days prior to the primary TKA procedure, and at least 60 days and not more than 180 days after TKA procedure", "eMeasureUuids": { "initialPopulationUuid": "F0D80FC4-5E5E-46F3-A519-1B99013E2761", "denominatorUuid": "D795B824-0575-47B3-93DB-D48CD5643677", "numeratorUuid": "0DD7EF36-2B1D-4447-8E52-BF9C4A3E7ED3", "denominatorExclusionUuid": "0E8BFC37-A4BA-4DE6-A6F3-DF4C188AB129" }, "name": "functionalStatus" } ], "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "orthopedicSurgery" ], "eMeasureUuid": "40280381-51f0-825b-0152-227ce2c81597" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Functional Status Assessments for Congestive Heart Failure", "description": "Percentage of patients 65 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessments", "nationalQualityStrategyDomain": "PCCEO", "measureType": "process", "measureId": "377", "eMeasureId": "CMS90v6", "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Patients with patient reported functional status assessment results (eg, VR-12; VR-36; MLHF-Q; KCCQ; PROMIS-10 Global Health, PROMIS-29) present in the EHR within two weeks before or during the initial encounter and the follow-up encounter during the measurement year", "eMeasureUuids": { "initialPopulationUuid": "AD37C6FE-2537-4A9B-8AD9-A372E3215F76", "denominatorUuid": "19ECF222-71EF-4D75-9CC2-19ED201107EA", "numeratorUuid": "F9B4C929-8F37-48D1-953C-489C028AE725", "denominatorExclusionUuid": "32DBECF3-11EC-40FB-B35D-FA1BF7366492" }, "name": "functionalStatus" } ], "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "submissionMethods": 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The change in FS assessed using FOTO (elbow, wrist and hand) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality", "nationalQualityStrategyDomain": "CCC", "measureType": "outcome", "measureId": "222", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0427", "isInverse": false, "strata": [ { "description": "A self-report outcome measure of functional status (FS) for patients 14 years+ with elbow, wrist or hand impairments. The change in FS assessed using FOTO (elbow, wrist and hand) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality", "name": "armImpairment" } ], "isHighPriority": true, "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Functional Status Change for Patients with Foot or Ankle Impairments", "description": "A self-report measure of change in functional status (FS) for patients 14 years+ with foot and ankle impairments. The change in functional status (FS) assessed using FOTO's (foot and ankle) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality", "nationalQualityStrategyDomain": "CCC", "measureType": "outcome", "measureId": "219", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0424", "isInverse": false, "strata": [ { "description": "A self-report measure of change in functional status (FS) for patients 14 years+ with foot and ankle impairments. The change in functional status (FS) assessed using FOTO’s (foot and ankle) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality", "name": "footImpairment" } ], "isHighPriority": true, "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Functional Status Change for Patients with General Orthopaedic Impairments", "description": "A self-report outcome measure of functional status (FS) for patients 14 years+ with general orthopaedic impairments (neck, cranium, mandible, thoracic spine, ribs or other general orthopaedic impairment). The change in FS assessed using FOTO (general orthopaedic) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality", "nationalQualityStrategyDomain": "CCC", "measureType": "outcome", "measureId": "223", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0428", "isInverse": false, "strata": [ { "description": "A self-report outcome measure of functional status (FS) for patients 14 years+ with general orthopaedic impairments (neck, cranium, mandible, thoracic spine, ribs or other general orthopedic impairment). The change in FS assessed using FOTO (general orthopedic) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality", "name": "orthoImpairment" } ], "isHighPriority": true, "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Functional Status Change for Patients with Hip Impairments", "description": "A self-report measure of change in functional status (FS) for patients 14 years+ with hip impairments. The change in functional status (FS) assessed using FOTO's (hip) PROM (patient- reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality", "nationalQualityStrategyDomain": "CCC", "measureType": "outcome", "measureId": "218", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0423", "isInverse": false, "strata": [ { "description": "A self-report measure of change in functional status (FS) for patients 14 years+ with hip impairments. The change in functional status (FS) assessed using FOTO’s (hip) PROM (patient- reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality", "name": "hipImpairment" } ], "isHighPriority": true, "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Functional Status Change for Patients with Knee Impairments", "description": "A self-report measure of change in functional status for patients 14 year+ with knee impairments. The change in functional status (FS) assessed using FOTO's (knee ) PROM (patient-reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality", "nationalQualityStrategyDomain": "CCC", "measureType": "outcome", "measureId": "217", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0422", "isInverse": false, "strata": [ { "description": "A self-report measure of change in functional status for patients 14 year+ with knee impairments. The change in functional status (FS) assessed using FOTO’s (knee) PROM (patient-reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality", "name": "kneeImpairment" } ], "isHighPriority": true, "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Functional Status Change for Patients with Lumbar Impairments", "description": "A self-report outcome measure of change in functional status for patients 14 years+ with lumbar impairments. The change in functional status (FS) assessed using FOTO (lumbar) PROM (patient reported outcome measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality", "nationalQualityStrategyDomain": "CCC", "measureType": "outcome", "measureId": "220", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0425", "isInverse": false, "strata": [ { "description": "A self-report outcome measure of change in functional status for patients 14 years+ with lumbar impairments. The change in functional status (FS) assessed using FOTO (lumbar) PROM (patient reported outcome measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality", "name": "lumbarImpairment" } ], "isHighPriority": true, "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Functional Status Change for Patients with Shoulder Impairments", "description": "A self-report outcome measure of change in functional status (FS) for patients 14 years+ with shoulder impairments. The change in functional status (FS) assessed using FOTO's (shoulder) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality", "nationalQualityStrategyDomain": "CCC", "measureType": "outcome", "measureId": "221", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0426", "isInverse": false, "strata": [ { "description": "A self-report outcome measure of change in functional status (FS) for patients 14 years+ with shoulder impairments. The change in functional status (FS) assessed using FOTO’s (shoulder) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality", "name": "shoulderImpariment" } ], "isHighPriority": true, "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)", "description": "Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "005", "eMeasureId": "CMS135v5", "nqfEMeasureId": "2907", "nqfId": "0081", "isInverse": false, "strata": [ { "description": "Patients who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge", "name": "LVEF<40%", "eMeasureUuids": { "initialPopulationUuid": "F3000871-B8FD-4F74-8892-281C250C11EA", "denominatorUuid": "C1E20830-ADFE-4D88-B979-166FA0820D5C", "numeratorUuid": "49E476F4-E8A1-48A6-B800-A8172073DBFB", "denominatorExceptionUuid": "41E08783-4358-4E0D-81BE-9616A8F58319" } } ], "isHighPriority": false, "primarySteward": "Physician Consortium for Performance Improvement", "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "internalMedicine", "cardiology", "hospitalists", "generalPracticeFamilyMedicine" ], "eMeasureUuid": "40280381-52fc-3a32-0153-62239c5d1ef6" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)", "description": "Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "008", "eMeasureId": "CMS144v5", "nqfEMeasureId": "2908", "nqfId": "0083", "isInverse": false, "strata": [ { "description": "Patients who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge", "name": "HF", "eMeasureUuids": { "initialPopulationUuid": "5ED1A428-A266-47E5-AE4F-DB97A65BB1D4", "denominatorUuid": "1E6C181E-91F6-4A61-82E0-7360C81CE3B0", "numeratorUuid": "ABBFFB54-E629-4520-875E-F6D18BC651B1", "denominatorExceptionUuid": "E9280685-6046-438D-AE45-0F7EDBA29C33" } } ], "isHighPriority": false, "primarySteward": "Physician Consortium for Performance Improvement", "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "hospitalists", "generalPracticeFamilyMedicine" ], "eMeasureUuid": "40280381-52fc-3a32-0153-1a3981870b45" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry", "description": "Percentage of patients aged 18 years and older, seen within a 12 month reporting period, with a diagnosis of chronic lymphocytic leukemia (CLL) made at any time during or prior to the reporting period who had baseline flow cytometry studies performed and documented in the chart", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "070", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0379", "isInverse": false, "strata": [ { "description": "Percentage of patients aged 18 years and older, seen within a 12 month reporting period, with a diagnosis of chronic lymphocytic leukemia (CLL) made at any time during or prior to the reporting period who had baseline flow cytometry studies performed and documented in the chart", "name": "CLL" } ], "isHighPriority": false, "primarySteward": "Physician Consortium for Performance Improvement", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Hematology: Multiple Myeloma: Treatment with Bisphosphonates", "description": "Percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12 month reporting period", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "069", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0380", "isInverse": false, "strata": [ { "description": "Percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12 month reporting period.", "name": "MM" } ], "isHighPriority": false, "primarySteward": "American Society of Hematology", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow", "description": "Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "067", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0377", "isInverse": false, "strata": [ { "description": "Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow", "name": "MDS" } ], "isHighPriority": false, "primarySteward": "American Society of Hematology", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy", "description": "Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy with documentation of iron stores within 60 days prior to initiating erythropoietin therapy", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "068", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0378", "isInverse": false, "strata": [ { "description": "Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy with documentation of iron stores within 60 days prior to initiating erythropoietin therapy", "name": "MDS" } ], "isHighPriority": false, "primarySteward": "American Society of Hematology", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options", "description": "Percentage of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or other qualified healthcare professional reviewed the range of treatment options appropriate to their genotype and demonstrated a shared decision making approach with the patient. To meet the measure, there must be documentation in the patient record of a discussion between the physician or other qualified healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment\n", "nationalQualityStrategyDomain": "PCCEO", "measureType": "process", "measureId": "390", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or other qualified healthcare professional reviewed the range of treatment options appropriate to their genotype and demonstrated a shared decision making approach with the patient. To meet the measure, there must be documentation in the patient record of a discussion between the physician or other qualified healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment", "name": "hepC" } ], "isHighPriority": true, "primarySteward": "American Gastroenterological Association", "submissionMethods": [ "registry" ], "measureSets": [ "gastroenterology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis", "description": "Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month reporting period", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "401", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month reporting period", "name": "hepC" } ], "isHighPriority": false, "primarySteward": "American Gastroenterological Association", "submissionMethods": [ "registry" ], "measureSets": [ "internalMedicine", "gastroenterology", "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies", "description": "Proportion of female patients (aged 18 years and older) with breast cancer who are human epidermal growth factor receptor 2 (HER2)/neu negative who are not administered HER2-targeted therapies", "nationalQualityStrategyDomain": "ECR", "measureType": "process", "measureId": "449", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1857", "isInverse": false, "strata": [ { "description": "Proportion of female patients (aged 18 years and older) with breast cancer who are human epidermal growth factor receptor 2 (HER2)/neu negative who are not administered HER2-targeted therapies", "name": "breastCancer" } ], "isHighPriority": true, "primarySteward": "American Society of Clinical Oncology", "submissionMethods": [ "registry" ], "measureSets": [ "generalOncology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "multiPerformanceRate", "title": "HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis", "description": "Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis jiroveci pneumonia (PCP) prophylaxis", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "160", "eMeasureId": "CMS52v5", "nqfEMeasureId": null, "nqfId": "0405", "isInverse": false, "strata": [ { "description": "Patients who were prescribed Pneumocystis jiroveci pneumonia (PCP) prophylaxis within 3 months of CD4 count below 200 cells/mm3", "eMeasureUuids": { "initialPopulationUuid": "E681DBF8-F827-4586-B3E0-178FF19EC3A2", "denominatorUuid": "04BF53CE-6993-4EA2-BFE5-66E36172B388", "numeratorUuid": "631C0B49-83F4-4A54-96C4-7E0766B2407C", "denominatorExceptionUuid": "58347456-D1F3-4BBB-9B35-5D42825A0AB3" }, "name": "CD4<200/mm3" }, { "description": "Patients who were prescribed Pneumocystis jiroveci pneumonia (PCP) prophylaxis within 3 months of CD4 count below 500 cells/mm3 or a CD4 percentage below 15%", "eMeasureUuids": { "initialPopulationUuid": "AAC578DB-1900-43BD-BBBF-50014A5457E5", "denominatorUuid": "1574973E-EB52-40C7-9709-25ABEDBA99A3", "numeratorUuid": "5B7AC4EC-547A-47E5-AC5E-618401175511", "denominatorExceptionUuid": "B7CCA1A6-F352-4A23-BC89-6FE9B60DC0C6" }, "name": "CD4<500/mm3OrCD4<15%" }, { "description": "Patients who were prescribed Pneumocystis jiroveci pneumonia (PCP) prophylaxis at the time of diagnosis of HIV", "eMeasureUuids": { "initialPopulationUuid": "AF36C4A9-8BD9-4E21-838D-A47A1845EB90", "denominatorUuid": "B95BC0D3-572E-462B-BAA2-46CD33A865CD", "numeratorUuid": "86F74F07-D593-44F6-AA12-405966400963" }, "name": "atDiagnosis" } ], "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "pediatrics" ], "eMeasureUuid": "40280381-51f0-825b-0152-2273af5a150b", "overallAlgorithm": "weightedAverage" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis", "description": "Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea, and syphilis screenings were performed at least once since the diagnosis of HIV infection", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "205", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0409", "isInverse": false, "strata": [ { "description": "Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea, and syphilis screenings were performed at least once since the diagnosis of HIV infection", "name": "HIV/AIDS" } ], "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "registry" ], "measureSets": [ "pediatrics" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "HIV Medical Visit Frequency", "description": "Percentage of patients, regardless of age with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits", "nationalQualityStrategyDomain": "ECR", "measureType": "process", "measureId": "340", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2079", "isInverse": false, "strata": [ { "description": "Percentage of patients, regardless of age with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits", "name": "HIV" } ], "isHighPriority": true, "primarySteward": "Health Resources and Services Administration", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "HIV Viral Load Suppression", "description": "The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year", "nationalQualityStrategyDomain": "ECC", "measureType": "outcome", "measureId": "338", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2082", "isInverse": false, "strata": [ { "description": "The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year", "name": "HIV" } ], "isHighPriority": true, "primarySteward": "Health Resources and Services Administration", "submissionMethods": [ "registry" ], "measureSets": [ "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "multiPerformanceRate", "title": "HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation", "description": "Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation This measure is reported as four rates stratified by age and gender:\n
", "nationalQualityStrategyDomain": "PS", "measureType": "outcome", "measureId": "392", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2474", "isInverse": false, "strata": [ { "description": "Females 18-64 years of age", "name": "18-64F" }, { "description": "Males 18-64 years of age", "name": "18-64M" }, { "description": "Females 65 years of age and older", "name": "65+F" }, { "description": "Males 65 years of age and older", "name": "65+M" }, { "description": "Overall percentage of patients with cardiac tamponade and/or pericardiocentesis occurring within 30 days Eligible clinicians should continue to report the measure as specified, with no additional steps needed to account for multiple performance rates.", "name": "overall" } ], "isHighPriority": true, "primarySteward": "The Heart Rhythm Society", "submissionMethods": [ "registry" ], "measureSets": [ "electrophysiologyCardiacSpecialist" ], "overallAlgorithm": "overallStratumOnly" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "multiPerformanceRate", "title": "HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate", "description": "Patients with physician-specific risk-standardized rates of procedural complications following the first time implantation of an ICD", "nationalQualityStrategyDomain": "PS", "measureType": "outcome", "measureId": "348", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Patients with first time implants with one or more complications or mortality within 30 days", "name": "30" }, { "description": "Patients with first time implants with one or more complications within 90 days", "name": "90" } ], "isHighPriority": true, "primarySteward": "The Heart Rhythm Society", "submissionMethods": [ "registry" ], "measureSets": [ "electrophysiologyCardiacSpecialist" ], "overallAlgorithm": "weightedAverage" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision", "description": "Infection rate following CIED device implantation, replacement, or revision\n", "nationalQualityStrategyDomain": "PS", "measureType": "outcome", "measureId": "393", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Infection rate following CIED device implantation, replacement, or revision", "name": "CIED" } ], "isHighPriority": true, "primarySteward": "The Heart Rhythm Society", "submissionMethods": [ "registry" ], "measureSets": [ "electrophysiologyCardiacSpecialist" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Hypertension: Improvement in Blood Pressure", "description": "Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period.", "nationalQualityStrategyDomain": "ECC", "measureType": "intermediateOutcome", "measureId": "373", "eMeasureId": "CMS65v6", "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Patients whose follow-up blood pressure is at least 10 mmHg less than their baseline blood pressure or is adequately controlled.\r\n\r\nIf a follow-up blood pressure reading is not recorded during the measurement year, the patient's blood pressure is assumed \"not improved.\"", "eMeasureUuids": { "initialPopulationUuid": "78CD5ACE-054C-43DF-A743-5F1E5BA4C099", "denominatorUuid": "CE973C7A-B867-422B-8408-83538E236039", "numeratorUuid": "F67DCC8F-4F0F-491B-957F-B21E721B040B", "denominatorExclusionUuid": "74F900B9-65DA-4E6C-BB2D-592189ABDDE5" }, "name": "lowerFollowupBP" } ], "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [], "eMeasureUuid": "40280381-51f0-825b-0152-227c2f851589" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Image Confirmation of Successful Excision of Image-Localized Breast Lesion", "description": "Image confirmation of lesion(s) targeted for image guided excisional biopsy or image guided partial mastectomy in patients with nonpalpable, image-detected breast lesion(s). Lesions may include: microcalcifications, mammographic or sonographic mass or architectural distortion, focal suspicious abnormalities on magnetic resonance imaging (MRI) or other breast imaging amenable to localization such as positron emission tomography (PET) mammography, or a biopsy marker demarcating site of confirmed pathology as established by previous core biopsy", "nationalQualityStrategyDomain": "PS", "measureType": "process", "measureId": "262", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Image confirmation of lesion(s) targeted for image guided excisional biopsy or image guided partial mastectomy in patients with nonpalpable, image-detected breast lesion(s). Lesions may include: microcalcifications, mammographic or sonographic mass or architectural distortion, focal suspicious abnormalities on magnetic resonance imaging (MRI) or other breast imaging amenable to localization such as positron emission tomography (PET) mammography, or a biopsy marker demarcating site of confirmed pathology as established by previous core biopsy", "name": "imageConfirmation" } ], "isHighPriority": true, "primarySteward": "American Society of Breast Surgeons", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "multiPerformanceRate", "title": "Immunizations for Adolescents", "description": "The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday", "nationalQualityStrategyDomain": "CPH", "measureType": "process", "measureId": "394", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1407", "isInverse": false, "strata": [ { "description": "Patients who had one dose of meningococcal vaccine on or between the patient’s 11th and 13th birthdays", "name": "meningococcal" }, { "description": "Patients who had one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) on or between the patient’s 10th and 13th birthdays", "name": "Tdap" }, { "description": "Patients who had at least three HPV vaccines with different dates of service on or between the patient’s 9th and 13th birthdays", "name": "HPV" }, { "description": "All patients who are compliant for Meningococcal, Tdap and HPV during the specified timeframes.", "name": "overall" } ], "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "registry" ], "measureSets": [ "generalPracticeFamilyMedicine", "pediatrics" ], "overallAlgorithm": "overallStratumOnly" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy", "description": "Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted within one year prior to receiving a first course of anti-TNF (tumor necrosis factor) therapy", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "275", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted within one year prior to receiving a first course of anti-TNF (tumor necrosis factor) therapy", "name": "IBD" } ], "isHighPriority": false, "primarySteward": "American Gastroenterological Association", "submissionMethods": [ "registry" ], "measureSets": [ "gastroenterology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury - Bone Loss Assessment", "description": "Percentage of patients aged 18 years and older with an inflammatory bowel disease encounter who were prescribed prednisone equivalents greater than or equal to 10 mg/day for 60 or greater consecutive days or a single prescription equating to 600 mg prednisone or greater for all fills and were documented for risk of bone loss once during the reporting year or the previous calendar year", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "271", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of patients aged 18 years and older with an inflammatory bowel disease encounter who were prescribed prednisone equivalents greater than or equal to 10 mg/day for 60 or greater consecutive days or a single prescription equating to 600 mg prednisone or greater for all fills and were documented for risk of bone loss once during the reporting year or the previous calendar year", "name": "IBD" } ], "isHighPriority": false, "primarySteward": "American Gastroenterological Association", "submissionMethods": [ "registry" ], "measureSets": [ "gastroenterology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "multiPerformanceRate", "title": "Initiation and Engagement of Alcohol and Other Drug Dependence Treatment", "description": "Percentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported.\na. Percentage of patients who initiated treatment within 14 days of the diagnosis.\nb. Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit.\n", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "305", "eMeasureId": "CMS137v5", "nqfEMeasureId": null, "nqfId": "0004", "isInverse": false, "strata": [ { "description": "Patients who initiated treatment within 14 days of the diagnosis", "eMeasureUuids": { "initialPopulationUuid": "EC2C5F63-AF76-4D3C-85F0-5423F8C28541", "denominatorUuid": "BC948E65-B908-493B-B48B-04AC342D3E6C", "numeratorUuid": "0BBF8596-4CFE-47F4-A0D7-9BEAB94BA4CD", "denominatorExclusionUuid": "56BC7FA2-C22A-4440-8652-2D3568852C60" }, "name": "14DaysOfDiagnosis" }, { "description": "Patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit", "eMeasureUuids": { "initialPopulationUuid": "1511AD34-240C-4F3E-A87B-73511AABFC5C", "denominatorUuid": "4A09AB89-D9B8-4DD1-BC4E-78BCFD1C5873", "numeratorUuid": "7FFA49C4-D708-491E-85FE-6855F0A725DF", "denominatorExclusionUuid": "206A891D-C3E1-4660-BF2C-6CDBDF9282FB" }, "name": "30DaysOfVisit" } ], "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [], "eMeasureUuid": "40280381-528a-60ff-0152-8e089ed20376", "overallAlgorithm": "simpleAverage" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)", "description": "The IVD All-or-None Measure is one outcome measure (optimal control). 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: \n
", "nationalQualityStrategyDomain": "ECC", "measureType": "intermediateOutcome", "measureId": "441", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "The IVD All-or-None Measure is one outcome measure (optimal control). 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 140/90 mm Hg -- And • Most recent tobacco status is Tobacco Free -- And • Daily Aspirin or Other Antiplatelet Unless Contraindicated -- And • Statin Use", "name": "IVDAllOrNone" } ], "isHighPriority": true, "primarySteward": "Wisconsin Collaborative for Healthcare Quality", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet", "description": "Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period.", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "204", "eMeasureId": "CMS164v5", "nqfEMeasureId": null, "nqfId": "0068", "isInverse": false, "strata": [ { "description": "Patients who had an active medication of aspirin or another antiplatelet during the measurement year", "name": "AMI", "eMeasureUuids": { "initialPopulationUuid": "C3E458D8-8ED4-4F09-A661-6221A2B9355D", "denominatorUuid": "FE6E1AA0-EE26-4F9E-A2FD-8E36058DCB47", "numeratorUuid": "0A3C80F4-A9FF-4BDF-B018-D647E7D777EB", "denominatorExclusionUuid": "D564DEEE-17E7-4442-921D-436E5113788A" } } ], "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "claims", "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "internalMedicine", "cardiology", "generalPracticeFamilyMedicine" ], "eMeasureUuid": "40280381-52fc-3a32-0153-5736a9401b9f" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "KRAS Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy", "description": "Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom KRAS gene mutation testing was performed", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "451", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1859", "isInverse": false, "strata": [ { "description": "Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom KRAS gene mutation testing was performed", "name": "KRASGeneMutation" } ], "isHighPriority": false, "primarySteward": "American Society of Clinical Oncology", "submissionMethods": [ "registry" ], "measureSets": [ "generalOncology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Lung Cancer Reporting (Biopsy/Cytology Specimens)", "description": "Pathology reports based on biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type or classified as NSCLC-NOS with an explanation included in the pathology report", "nationalQualityStrategyDomain": "CCC", "measureType": "outcome", "measureId": "395", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Pathology reports based on biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type or classified as NSCLC-NOS with an explanation included in the pathology report", "name": "lungCancer" } ], "isHighPriority": true, "primarySteward": "College of American Pathologists", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "pathology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Lung Cancer Reporting (Resection Specimens)", "description": "Pathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer, histologic type", "nationalQualityStrategyDomain": "CCC", "measureType": "outcome", "measureId": "396", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Pathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer, histologic type", "name": "lungCarcinoma" } ], "isHighPriority": true, "primarySteward": "College of American Pathologists", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "pathology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Maternal Depression Screening", "description": "The percentage of children who turned 6 months of age during the measurement year, who had a face-to-face visit between the clinician and the child during child's first 6 months, and who had a maternal depression screening for the mother at least once between 0 and 6 months of life.\n", "nationalQualityStrategyDomain": "CPH", "measureType": "process", "measureId": "372", "eMeasureId": "CMS82v4", "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Children with documentation of maternal screening or treatment for postpartum depression for the mother.", "eMeasureUuids": { "initialPopulationUuid": "D3ADB281-2F53-4BE6-89A9-124480DE787D", "denominatorUuid": "6B845134-C1B7-4383-AFB3-1FFB7EAD359B", "numeratorUuid": "D2A5FF72-DE5E-413A-829E-C763FC07DF4A" }, "name": "screeningOrTreatment" } ], "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [], "eMeasureUuid": "40280381-51f0-825b-0152-2295c55c16aa" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Maternity Care: Elective Delivery or Early Induction Without Medical Indication at >= 37 and < 39 Weeks (Overuse)", "description": "Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at\n>= 37 and < 39 weeks of gestation completed who had elective deliveries or early inductions without medical indication\n", "nationalQualityStrategyDomain": "PS", "measureType": "outcome", "measureId": "335", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at ≥ 37 and < 39 weeks of gestation completed who had elective deliveries or early inductions without medical indication", "name": "birth" } ], "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Maternity Care: Post-Partum Follow-Up and Care Coordination", "description": "Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for post-partum care within 8 weeks of giving birth who received a breast feeding evaluation and education, post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and family and contraceptive planning", "nationalQualityStrategyDomain": "CCC", "measureType": "process", "measureId": "336", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for post-partum care within 8 weeks of giving birth who received a breast feeding evaluation and education, post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and family and contraceptive planning", "name": "postPartum" } ], "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Medication Management for People with Asthma", "description": "The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period", "nationalQualityStrategyDomain": "ECR", "measureType": "process", "measureId": "444", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1799", "isInverse": false, "strata": [ { "description": "The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period", "name": "asthma" } ], "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "generalPracticeFamilyMedicine", "pediatrics" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "multiPerformanceRate", "title": "Medication Reconciliation Post-Discharge", "description": "The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record.\nThis measure is reported as three rates stratified by age group:\n
", "nationalQualityStrategyDomain": "CCC", "measureType": "process", "measureId": "046", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0097", "isInverse": false, "strata": [ { "description": "Performance Rate 1: Percentage of discharges from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) for patients 18-64 years of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on- going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record", "name": "18-64" }, { "description": "Performance Rate 2: Percentage of discharges from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) for patients 65 years and older seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on- going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record", "name": "65+" }, { "description": "Total Rate (Overall Performance Rate): Percentage of discharges from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record", "name": "overall" } ], "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "claims", "cmsWebInterface", "registry" ], "measureSets": [], "overallAlgorithm": "overallStratumOnly" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Melanoma: Continuity of Care - Recall System", "description": "Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month period, into a recall system that includes:\n
", "nationalQualityStrategyDomain": "CCC", "measureType": "structure", "measureId": "137", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0650", "isInverse": false, "strata": [ { "description": "Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month period, into a recall system that includes: • A target date for the next complete physical skin exam, • A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment", "name": "melanoma" } ], "isHighPriority": true, "primarySteward": "American Academy of Dermatology", "submissionMethods": [ "registry" ], "measureSets": [ "dermatology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Melanoma: Coordination of Care", "description": "Percentage of patient visits, regardless of age, with a new occurrence of melanoma who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis", "nationalQualityStrategyDomain": "CCC", "measureType": "process", "measureId": "138", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of patient visits, regardless of age, with a new occurrence of melanoma that have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis", "name": "melanoma" } ], "isHighPriority": true, "primarySteward": "American Academy of Dermatology", "submissionMethods": [ "registry" ], "measureSets": [ "dermatology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Melanoma: Overutilization of Imaging Studies in Melanoma", "description": "Percentage of patients, regardless of age, with a current diagnosis of Stage 0 through IIC melanoma or a history of melanoma of any stage, without signs or symptoms suggesting systemic spread, seen for an office visit during the one-year measurement period, for whom no diagnostic imaging studies were ordered", "nationalQualityStrategyDomain": "ECR", "measureType": "process", "measureId": "224", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0562", "isInverse": false, "strata": [ { "description": "Percentage of patients, regardless of age, with a current diagnosis of Stage 0 through IIC melanoma or a history of melanoma of any stage, without signs or symptoms suggesting systemic spread, seen for an office visit during the one- year measurement period, for whom no diagnostic imaging studies were ordered", "name": "melanoma" } ], "isHighPriority": true, "primarySteward": "American Academy of Dermatology", "submissionMethods": [ "registry" ], "measureSets": [ "dermatology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Melanoma Reporting", "description": "Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness and ulceration and for pT1, mitotic rate", "nationalQualityStrategyDomain": "CCC", "measureType": "outcome", "measureId": "397", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness and ulceration and for pT1, mitotic rate", "name": "melanoma" } ], "isHighPriority": true, "primarySteward": "College of American Pathologists", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "pathology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Non-Recommended Cervical Cancer Screening in Adolescent Females", "description": "The percentage of adolescent females 16-20 years of age who were screened unnecessarily for cervical cancer", "nationalQualityStrategyDomain": "PS", "measureType": "process", "measureId": "443", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "The percentage of adolescent females 16–20 years of age who were screened unnecessarily for cervical cancer", "name": "cervicalCancer" } ], "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "registry" ], "measureSets": [ "obstetricsGynecology", "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone 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"metricType": "singlePerformanceRate", "title": "Oncology: Medical and Radiation - Pain Intensity Quantified", "description": "Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified", "nationalQualityStrategyDomain": "PCCEO", "measureType": "process", "measureId": "143", "eMeasureId": "CMS157v5", "nqfEMeasureId": null, "nqfId": "0384", "isInverse": false, "strata": [ { "description": "Patient visits in which pain intensity is quantified", "name": "cancer", "eMeasureUuids": { "initialPopulationUuid": "8494E3CD-7119-4471-9F2F-42540A797498", "denominatorUuid": "D1358E7F-9C53-414C-9D4D-DEF7AE9B6E68", "numeratorUuid": "95484C04-C98A-4A77-B2A7-9FE583060582" } } ], "isHighPriority": true, "primarySteward": "Physician Consortium for Performance Improvement", "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "generalOncology", "radiationOncology" ], "eMeasureUuid": "40280381-52fc-3a32-0153-1a4425a90b6c" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Oncology: Medical and Radiation - Plan of Care for Pain", "description": "Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain", "nationalQualityStrategyDomain": "PCCEO", "measureType": "process", "measureId": "144", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0383", "isInverse": false, "strata": [ { "description": "Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain", "name": "cancer" } ], "isHighPriority": true, "primarySteward": "American Society of Clinical Oncology", "submissionMethods": [ "registry" ], "measureSets": [ "radiationOncology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Oncology: Radiation Dose Limits to Normal Tissues", "description": "Percentage of patients, regardless of age, with a diagnosis of breast, rectal, pancreatic or lung cancer receiving 3D conformal radiation therapy who had documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues", "nationalQualityStrategyDomain": "PS", "measureType": "process", "measureId": "156", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0382", "isInverse": false, "strata": [ { "description": "Percentage of patients, regardless of age, with a diagnosis of breast, rectal, pancreatic or lung cancer receiving 3D conformal radiation therapy who had documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues", "name": "cancer" } ], "isHighPriority": true, "primarySteward": "American Society for Radiation Oncology", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "radiationOncology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk", "description": "Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infection", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "400", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infection", "name": "HCV" } ], "isHighPriority": false, "primarySteward": "Physician Consortium for Performance Improvement", "submissionMethods": [ "registry" ], "measureSets": [ "internalMedicine", "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Operative Mortality Stratified by the Five STS-EACTS Mortality Categories", "description": "Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool", "nationalQualityStrategyDomain": "PS", "measureType": "outcome", "measureId": "446", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0733", "isInverse": false, "strata": [ { "description": "Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool", "name": "heartSurgery" } ], "isHighPriority": true, "primarySteward": "Society of Thoracic Surgeons", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Opioid Therapy Follow-up Evaluation", "description": "All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "408", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record", "name": "opiates" } ], "isHighPriority": false, "primarySteward": "American Academy of Neurology", "submissionMethods": [ "registry" ], "measureSets": [ "internalMedicine", "neurology", "physicalMedicine", "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "multiPerformanceRate", "title": "Optimal Asthma Control", "description": "Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbation", "nationalQualityStrategyDomain": "ECC", "measureType": "outcome", "measureId": "398", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Overall Percentage for patients (aged 5-50 years) with well-controlled asthma, without elevated risk of exacerbation.", "name": "overall" }, { "description": "Percentage of pediatric patients (aged 5-17 years) with well-controlled asthma, without elevated risk of exacerbation.", "name": "5-17" }, { "description": "Percentage of adult patients (aged 18-50 years) with well-controlled asthma, without elevated risk of exacerbation.", "name": "18-50" }, { "description": "Asthma well-controlled (take the most recent ACT) for patients 5 to 17 with Asthma", "name": "ACT5-17" }, { "description": "Asthma well-controlled (take the most recent ACT) for patients 18 to 50 with Asthma", "name": "ACT18-50" }, { "description": "Patient not at elevated risk of exacerbation for patients 5 to 17 with Asthma", "name": "lowRisk5-17" }, { "description": "Patient not at elevated risk of exacerbation for patients 18 to 50 with Asthma", "name": "lowRisk18-50" } ], "isHighPriority": true, "primarySteward": "Minnesota Community Measurement", "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "generalPracticeFamilyMedicine" ], "overallAlgorithm": "overallStratumOnly" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines", "description": "Percentage of final reports for computed tomography (CT) imaging studies of the thorax for patients aged 18 years and older with documented follow-up recommendations for incidentally detected pulmonary nodules (e.g., follow-up CT imaging studies needed or that no follow-up is needed) based at a minimum on nodule size AND patient risk factors", "nationalQualityStrategyDomain": "CCC", "measureType": "process", "measureId": "364", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of final reports for computed tomography (CT) imaging studies of the thorax for patients aged 18 years and older with documented follow-up recommendations for incidentally detected pulmonary nodules (e.g., follow-up CT imaging studies needed or that no follow-up is needed) based at a minimum on nodule size patient risk factors", "name": "CT" } ], "isHighPriority": true, "primarySteward": "American College of Radiology", "submissionMethods": [ "registry" ], "measureSets": [ "diagnosticRadiology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes", "description": "Percentage of final reports for computed tomography (CT) studies performed for all patients, regardless of age, which document that Digital Imaging and Communications in Medicine (DICOM) format image data are available to non-affiliated external healthcare facilities or entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study", "nationalQualityStrategyDomain": "CCC", "measureType": "structure", "measureId": "362", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of final reports for computed tomography (CT) studies performed for all patients, regardless of age, which document that Digital Imaging and Communications in Medicine (DICOM) format image data are available to non- affiliated external healthcare facilities or entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study", "name": "CT" } ], "isHighPriority": true, "primarySteward": "American College of Radiology", "submissionMethods": [ "registry" ], "measureSets": [ "diagnosticRadiology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies", "description": "Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study", "nationalQualityStrategyDomain": "PS", "measureType": "process", "measureId": "360", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study", "name": "CT" } ], "isHighPriority": true, "primarySteward": "American College of Radiology", "submissionMethods": [ "registry" ], "measureSets": [ "diagnosticRadiology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry", "description": "Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that are reported to a radiation dose index registry that is capable of collecting at a minimum selected data elements", "nationalQualityStrategyDomain": "PS", "measureType": "structure", "measureId": "361", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that are reported to a radiation dose index registry that is capable of collecting at a minimum selected data elements", "name": "CT" } ], "isHighPriority": true, "primarySteward": "American College of Radiology", "submissionMethods": [ "registry" ], "measureSets": [ "diagnosticRadiology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive", "description": "Percentage of final reports of computed tomography (CT) studies performed for all patients, regardless of age, which document that a search for Digital Imaging and Communications in Medicine (DICOM) format images was conducted for prior patient CT imaging studies completed at non-affiliated external healthcare facilities or entities within the past 12-months and are available through a secure, authorized, media-free, shared archive prior to an imaging study being performed", "nationalQualityStrategyDomain": "CCC", "measureType": "structure", "measureId": "363", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of final reports of computed tomography (CT) studies performed for all patients, regardless of age, which document that a search for Digital Imaging and Communications in Medicine (DICOM) format images was conducted for prior patient CT imaging studies completed at non-affiliated external healthcare facilities or entities within the past 12-months and are available through a secure, authorized, media-free, shared archive prior to an imaging study being performed", "name": "CT" } ], "isHighPriority": true, "primarySteward": "American College of Radiology", "submissionMethods": [ "registry" ], "measureSets": [ "diagnosticRadiology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description", "description": "Percentage of computed tomography (CT) imaging reports for all patients, regardless of age, with the imaging study named according to a standardized nomenclature and the standardized nomenclature is used in institution's computer systems", "nationalQualityStrategyDomain": "CCC", "measureType": "process", "measureId": "359", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of computed tomography (CT) imaging reports for all patients, regardless of age, with the imaging study named according to a standardized nomenclature and the standardized nomenclature is used in institution’s computer systems", "name": "CT" } ], "isHighPriority": true, "primarySteward": "American College of Radiology", "submissionMethods": [ "registry" ], "measureSets": [ "diagnosticRadiology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Osteoarthritis (OA): Function and Pain Assessment", "description": "Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain", "nationalQualityStrategyDomain": "PCCEO", "measureType": "process", "measureId": "109", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain", "name": "OA" } ], "isHighPriority": true, "primarySteward": "American Academy of Orthopedic Surgeons", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "internalMedicine", "orthopedicSurgery", "physicalMedicine", "preventiveMedicine", "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Osteoporosis Management in Women Who Had a Fracture", "description": "The percentage of women age 50-85 who suffered a fracture and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "418", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0053", "isInverse": false, "strata": [ { "description": "The percentage of women age 50-85 who suffered a fracture and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture", "name": "osteoporosis" } ], "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "internalMedicine", "obstetricsGynecology", "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination", "description": "Percentage of patients with a diagnosis of primary headache disorder whom advanced brain imaging was not ordered", "nationalQualityStrategyDomain": "ECR", "measureType": "efficiency", "measureId": "419", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of patients with a diagnosis of primary headache disorder whom advanced brain imaging was not ordered", "name": "headache" } ], "isHighPriority": true, "primarySteward": "American Academy of Neurology", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "neurology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Pain Assessment and Follow-Up", "description": "Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present", "nationalQualityStrategyDomain": "CCC", "measureType": "process", "measureId": "131", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0420", "isInverse": false, "strata": [ { "description": "Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit documentation of a follow-up plan when pain is present", "name": "painAssessment" } ], "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "physicalMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Pain Brought Under Control Within 48 Hours", "description": "Patients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) that report pain was brought to a comfortable level within 48 hours", "nationalQualityStrategyDomain": "PCCEO", "measureType": "outcome", "measureId": "342", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Patients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) that report pain was brought to a comfortable level within 48 hours", "name": "pain" } ], "isHighPriority": true, "primarySteward": "National Hospice and Palliative Care Organization", "submissionMethods": [ "registry" ], "measureSets": [ "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Parkinson's Disease: Cognitive Impairment or Dysfunction Assessment", "description": "All patients with a diagnosis of Parkinson's disease who were assessed for cognitive impairment or dysfunction in the last 12 months", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "291", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "All patients with a diagnosis of Parkinson’s disease who were assessed for cognitive impairment or dysfunction in the last 12 months", "name": "parkinsons" } ], "isHighPriority": false, "primarySteward": "American Academy of Neurology", "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Parkinson's Disease: Parkinson's Disease Medical and Surgical Treatment Options Reviewed", "description": "All patients with a diagnosis of Parkinson's disease (or caregiver(s), as appropriate) who had the Parkinson's disease treatment options (e.g., non-pharmacological treatment, pharmacological treatment, or surgical treatment) reviewed at least annually", "nationalQualityStrategyDomain": "CCC", "measureType": "process", "measureId": "294", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "All patients with a diagnosis of Parkinson’s disease (or caregiver(s), as appropriate) who had the Parkinson’s disease treatment options (e.g., non-pharmacological treatment, pharmacological treatment, or surgical treatment) reviewed at least once annually", "name": "parkinsons" } ], "isHighPriority": true, "primarySteward": "American Academy of Neurology", "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Parkinson's Disease: Psychiatric Symptoms Assessment for Patients with Parkinson's Disease", "description": "All patients with a diagnosis of Parkinson's disease who were assessed for psychiatric symptoms (e.g., psychosis, depression, anxiety disorder, apathy, or impulse control disorder) in the last 12 months", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "290", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "All patients with a diagnosis of Parkinson’s disease who were assessed for psychiatric symptoms (e.g., psychosis, depression, anxiety disorder, apathy, or impulse control disorder) in the last 12 months", "name": "parkinsons" } ], "isHighPriority": false, "primarySteward": "American Academy of Neurology", "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Parkinson's Disease: Rehabilitative Therapy Options", "description": "All patients with a diagnosis of Parkinson's Disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (e.g., physical, occupational, or speech therapy) discussed in the last 12 months", "nationalQualityStrategyDomain": "CCC", "measureType": "process", "measureId": "293", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "All patients with a diagnosis of Parkinson’s Disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (e.g., physical, occupational, or speech therapy) discussed in the last 12 months", "name": "parkinsons" } ], "isHighPriority": true, "primarySteward": "American Academy of Neurology", "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Patient-Centered Surgical Risk Assessment and Communication", "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": "PCCEO", "measureType": "process", "measureId": "358", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "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, 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"strata": [ { "description": "Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer and KRAS gene mutation spared treatment with anti-EGFR monoclonal antibodies", "name": "colorectalCancer" } ], "isHighPriority": true, "primarySteward": "American Society of Clinical Oncology", "submissionMethods": [ "registry" ], "measureSets": [ "generalOncology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Pediatric Kidney Disease: Adequacy of Volume Management", "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) undergoing maintenance hemodialysis in an outpatient dialysis facility have an assessment of the adequacy of volume management from a nephrologist", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "327", "eMeasureId": null, 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[ { "description": "Percent of asymptomatic patients undergoing CEA who experience stroke or death following surgery while in the hospital", "name": "CEA" } ], "isHighPriority": true, "primarySteward": "Society for Vascular Surgeons", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure", "description": "Inpatients assigned to endovascular treatment for obstructive arterial disease, the percent of patients who undergo unplanned major amputation or surgical bypass within 48 hours of the index procedure", "nationalQualityStrategyDomain": "PS", "measureType": "outcome", "measureId": "437", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Inpatients assigned to endovascular treatment for obstructive arterial 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"nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "279", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured", "name": "sleepApnea" } ], "isHighPriority": false, "primarySteward": "American Academy of Sleep Medicine", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Sleep Apnea: Assessment of Sleep Symptoms", "description": "Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea that includes documentation of an assessment of sleep symptoms, including presence or 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non-steroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure", "nationalQualityStrategyDomain": "CCC", "measureType": "process", "measureId": "350", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of patients regardless of age undergoing a total knee replacement with documented shared decision- making with discussion of conservative (non-surgical) therapy (e.g., non-steroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure", "name": "kneeReplacement" } ], "isHighPriority": true, "primarySteward": "American Association of Hip and Knee Surgeons", "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation", "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": "PS", "measureType": "process", "measureId": "351", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "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)", "name": "kneeReplacement" } ], "isHighPriority": true, "primarySteward": "American Association of Hip and Knee Surgeons", "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Trastuzumab Received By Patients With AJCC Stage I (T1c) - III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy", "description": "Proportion of female patients (aged 18 years and older) with AJCC stage I (T1c) - III, human epidermal growth factor receptor 2 (HER2) positive breast cancer receiving adjuvant chemotherapy who are also receiving trastuzumab", "nationalQualityStrategyDomain": "ECR", "measureType": "process", "measureId": "450", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1858", "isInverse": false, "strata": [ { "description": "Proportion of female patients (aged 18 years and older) with AJCC stage I (T1c) – III, human epidermal growth factor receptor 2 (HER2) positive breast cancer receiving adjuvant chemotherapy who are also receiving trastuzumab", "name": "AJCC" } ], "isHighPriority": true, "primarySteward": "American Society of Clinical Oncology", "submissionMethods": [ "registry" ], "measureSets": [ "generalOncology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Tuberculosis (TB) Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier", "description": "Percentage of patients 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": "ECC", "measureType": "process", "measureId": "337", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of patients 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", "name": "tuberculosis" } ], "isHighPriority": false, "primarySteward": "American Academy of Dermatology", "submissionMethods": [ "registry" ], "measureSets": [ "dermatology", "rheumatology", "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain", "description": "Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "254", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0651", "isInverse": false, "strata": [ { "description": "Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location", "name": "ED" } ], "isHighPriority": false, "primarySteward": "American College of Emergency Physicians", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "emergencyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Unplanned Hospital Readmission within 30 Days of Principal Procedure", "description": "Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure", "nationalQualityStrategyDomain": "ECC", "measureType": "outcome", "measureId": "356", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure", "name": "readmission" } ], "isHighPriority": true, "primarySteward": "American College of Surgeons", "submissionMethods": [ "registry" ], "measureSets": [ "generalSurgery" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Unplanned Reoperation within the 30 Day Postoperative Period", "description": "Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period", "nationalQualityStrategyDomain": "PS", "measureType": "outcome", "measureId": "355", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period", "name": "reoperation" } ], "isHighPriority": true, "primarySteward": "American College of Surgeons", "submissionMethods": [ "registry" ], "measureSets": [ "generalSurgery" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older", "description": "Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months", "nationalQualityStrategyDomain": "ECC", "measureType": "process", "measureId": "048", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months", "name": "UTI" } ], "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "obstetricsGynecology", "preventiveMedicine", "urology" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older", "description": "Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months", "nationalQualityStrategyDomain": "PCCEO", "measureType": "process", "measureId": "050", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months", "name": "UTI" } ], "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "claims", "registry" ], "measureSets": [ "internalMedicine", "obstetricsGynecology", "urology", "generalPracticeFamilyMedicine" ] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "multiPerformanceRate", "title": "Use of High-Risk Medications in the Elderly", "description": "Percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported.\na. Percentage of patients who were ordered at least one high-risk medication. \nb. Percentage of patients who were ordered at least two different high-risk medications.", "nationalQualityStrategyDomain": "PS", "measureType": "process", "measureId": "238", "eMeasureId": "CMS156v5", "nqfEMeasureId": null, "nqfId": "0022", "isInverse": true, "strata": [ { "description": "Patients with an order for at least one high-risk medication during the measurement period.", "name": "overall", "eMeasureUuids": { "initialPopulationUuid": "C7BCE5A3-AC0D-440E-AA29-C98239F37A8B", "denominatorUuid": "07F04D61-0383-487E-942C-690BBBC6437D", "numeratorUuid": "7A0001AC-4BE0-4FAA-94AE-4843C9FFFCA8" } }, { "description": "Patients with an order for at least two different high-risk medications during the measurement period.", "name": "2+", "eMeasureUuids": { "initialPopulationUuid": "BC02D7CE-7133-46C6-8592-658668B09948", "denominatorUuid": "00401314-1B01-4896-A9FC-E991CDF29B6B", "numeratorUuid": "FA7BF805-C21E-4077-B43E-C63F8D17B5CF" } } ], "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [], "overallAlgorithm": "overallStratumOnly", "eMeasureUuid": "40280381-52fc-3a32-0153-56d2b4f01ae5" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Use of Imaging Studies for Low Back Pain", "description": "Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis.", "nationalQualityStrategyDomain": "ECR", "measureType": "process", "measureId": "312", "eMeasureId": "CMS166v6", "nqfEMeasureId": null, "nqfId": "0052", "isInverse": false, "strata": [ { "description": "Patients without an imaging study conducted on the date of the outpatient or emergency department visit or in the 28 days following the outpatient or emergency department visit", "eMeasureUuids": { "initialPopulationUuid": "45D3A3ED-A7D6-45B9-AC95-647BFFE7018E", "denominatorUuid": "0E27156C-B8EB-48E7-A588-4AB97A0914E1", "numeratorUuid": "13C60632-9CF4-491B-82E9-A06118111C44", "denominatorExclusionUuid": "0E9E3C94-6AA0-4C3C-A311-72CB0F2698B6" }, "name": "noStudy28Days" } ], "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "orthopedicSurgery", "physicalMedicine", "generalPracticeFamilyMedicine" ], "eMeasureUuid": "40280381-51f0-825b-0152-22ba7621182e" }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", "title": "Varicose Vein Treatment with Saphenous Ablation: Outcome Survey", "description": "Percentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease specific patient reported outcome survey instrument after treatment", "nationalQualityStrategyDomain": "ECC", "measureType": "outcome", "measureId": "420", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "isInverse": false, "strata": [ { "description": "Percentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease specific patient reported outcome survey instrument after treatment", "name": "CEAP_C2-S" } ], "isHighPriority": true, "primarySteward": "Society of Interventional Radiology ", "submissionMethods": [ "registry" ], "measureSets": [] }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "multiPerformanceRate", "title": "Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents", "description": "Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported.\n\n - Percentage of patients with height, weight, and body mass index (BMI) percentile documentation\n - Percentage of patients with counseling for nutrition\n - Percentage of patients with counseling for physical activity", "nationalQualityStrategyDomain": "CPH", "measureType": "process", "measureId": "239", "eMeasureId": "CMS155v5", "nqfEMeasureId": null, "nqfId": "0024", "isInverse": false, "strata": [ { "description": "Patients who had a height, weight and body mass index (BMI) percentile recorded during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "0ADE9325-3FB7-402F-AD89-34C9F2753D03", "denominatorUuid": "933D86C8-2C2B-4AFF-AE81-DF2F9882A3A4", "numeratorUuid": "61887626-5457-484C-A02D-75EF8547F559", "denominatorExclusionUuid": "6938F4DD-D5AB-4C40-BA03-EB0F0959615C" }, "name": "BMI" }, { "description": "Patients who had counseling for nutrition during a visit that occurs during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "25286925-4221-4396-9DE0-60EA606924DF", "denominatorUuid": "CFB8E3E2-FF4F-4D25-B613-7EC142BAE8A9", "numeratorUuid": "EEAD441F-B3B2-4DC9-A890-B35E14B38EA7", "denominatorExclusionUuid": "A399FA9C-48CF-41E5-812A-3445188B8301" }, "name": "nutrition" }, { "description": "Patients who had counseling for physical activity during a visit that occurs during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "48747E9D-674C-4013-9585-268114190119", "denominatorUuid": "208B74F2-6592-4381-BEC1-EB136004C3B2", "numeratorUuid": "21409D88-B5E3-4745-8DE2-D99DBB9F4DF0", "denominatorExclusionUuid": "507F7EC3-D380-48BE-B920-ABB1EB258256" }, "name": "physicalActivity" } ], "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "pediatrics" ], "eMeasureUuid": "40280381-51f0-825b-0152-22b695b217dc", "overallAlgorithm": "simpleAverage" } ]