| eCQM Title | \r\nDischarged on Statin Medication | \r\n ||
| eCQM Identifier (Measure Authoring Tool) | \r\n105 | \r\neCQM Version number | \r\n8.1.000 | \r\n
| NQF Number | \r\nNot Applicable | \r\nGUID | \r\n1f503318-bb8d-4b91-af63-223ae0a2328e | \r\n
| Measurement Period | \r\nJanuary 1, 20XX through December 31, 20XX | \r\n||
| Measure Steward | \r\nThe Joint Commission | \r\n||
| Measure Developer | \r\nThe Joint Commission | \r\n||
| Endorsed By | \r\nNone | \r\n||
| Description | \r\n\r\n | \r\n||
| Copyright | \r\n\r\n | \r\n||
| Disclaimer | \r\n\r\n | \r\n||
| Measure Scoring | \r\nProportion | \r\n||
| Measure Type | \r\nProcess | \r\n||
| Stratification | \r\n\r\n | \r\n||
| Risk Adjustment | \r\n\r\n | \r\n||
| Rate Aggregation | \r\n\r\n | \r\n||
| Rationale | \r\n\r\n | \r\n||
| Clinical Recommendation Statement | \r\n\r\n | \r\n||
| Improvement Notation | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Definition | \r\n\r\n | \r\n||
| Guidance | \r\n\r\n | \r\n||
| Transmission Format | \r\n\r\n | \r\n||
| Initial Population | \r\n\r\n | \r\n||
| Denominator | \r\n\r\n | \r\n||
| Denominator Exclusions | \r\n\r\n | \r\n||
| Numerator | \r\n\r\n | \r\n||
| Numerator Exclusions | \r\n\r\n | \r\n||
| Denominator Exceptions | \r\n\r\n | \r\n||
| Supplemental Data Elements | \r\n\r\n | \r\n
TJC."Encounter with Principal Diagnosis and Age"\r\n
TJC."Ischemic Stroke Encounter"\r\n
TJC."Ischemic Stroke Encounters with Discharge Disposition"\r\n union TJC."Comfort Measures during Hospitalization"\r\n
TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter\r\n with "Statin at Discharge" DischargeStatin\r\n such that DischargeStatin.authorDatetime during IschemicStrokeEncounter.relevantPeriod\r\n
( TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter\r\n with "Statin Not Given at Discharge" NoDischargeStatin\r\n such that NoDischargeStatin.authorDatetime during IschemicStrokeEncounter.relevantPeriod\r\n )\r\n union ( TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter\r\n with "Statin Allergy" StatinAllergy\r\n such that StatinAllergy.prevalencePeriod starts on or before end of IschemicStrokeEncounter.relevantPeriod\r\n )\r\n union "Encounter with Max LDL less than 70 mg per dL"\r\n
TJC."Ischemic Stroke Encounter"\r\n
( TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter\r\n with "Statin Not Given at Discharge" NoDischargeStatin\r\n such that NoDischargeStatin.authorDatetime during IschemicStrokeEncounter.relevantPeriod\r\n )\r\n union ( TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter\r\n with "Statin Allergy" StatinAllergy\r\n such that StatinAllergy.prevalencePeriod starts on or before end of IschemicStrokeEncounter.relevantPeriod\r\n )\r\n union "Encounter with Max LDL less than 70 mg per dL"\r\n
TJC."Ischemic Stroke Encounters with Discharge Disposition"\r\n union TJC."Comfort Measures during Hospitalization"\r\n
TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter\r\n where Max(["Laboratory Test, Performed": "LDL-c"] Ldl\r\n where Ldl.resultDatetime during Interval[Global."ToDate"(start of IschemicStrokeEncounter.relevantPeriod - 30 days), end of IschemicStrokeEncounter.relevantPeriod]\r\n return Ldl.result as Quantity\r\n )%26lt; 70 'mg/dL'\r\n
TJC."Encounter with Principal Diagnosis and Age"\r\n
TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter\r\n with "Statin at Discharge" DischargeStatin\r\n such that DischargeStatin.authorDatetime during IschemicStrokeEncounter.relevantPeriod\r\n
["Patient Characteristic Ethnicity": "Ethnicity"]\r\n
["Patient Characteristic Payer": "Payer"]\r\n
["Patient Characteristic Race": "Race"]\r\n
["Patient Characteristic Sex": "ONC Administrative Sex"]\r\n
["Allergy/Intolerance": "Statin Allergen"]\r\n
["Medication, Discharge": "Statin Grouper"]\r\n
["Medication, Not Discharged": "Statin Grouper"] NoStatinDischarge\r\n where NoStatinDischarge.negationRationale in "Medical Reason"\r\n or NoStatinDischarge.negationRationale in "Patient Refusal"\r\n
"Non Elective Inpatient Encounter" NonElectiveEncounter\r\n where NonElectiveEncounter.principalDiagnosis in "Hemorrhagic Stroke"\r\n or NonElectiveEncounter.principalDiagnosis in "Ischemic Stroke"\r\n
"Ischemic Stroke Encounter" IschemicStrokeEncounter\r\n with "Intervention Comfort Measures" ComfortMeasure\r\n such that Coalesce(start of ComfortMeasure.relevantPeriod, ComfortMeasure.authorDatetime)during Global."HospitalizationWithObservation"(IschemicStrokeEncounter)\r\n
"All Stroke Encounter" AllStrokeEncounter\r\n with ["Patient Characteristic Birthdate": "Birth date"] BirthDate\r\n such that Global."CalendarAgeInYearsAt"(BirthDate.birthDatetime, start of AllStrokeEncounter.relevantPeriod)%26gt;= 18\r\n
["Intervention, Order": "Comfort Measures"]\r\n union ["Intervention, Performed": "Comfort Measures"]\r\n
"Encounter with Principal Diagnosis and Age" EncounterWithAge\r\n where EncounterWithAge.principalDiagnosis in "Ischemic Stroke"\r\n
( ( "Ischemic Stroke Encounter" IschemicStrokeEncounter\r\n where IschemicStrokeEncounter.dischargeDisposition in "Discharge To Acute Care Facility"\r\n or IschemicStrokeEncounter.dischargeDisposition in "Left Against Medical Advice"\r\n or IschemicStrokeEncounter.dischargeDisposition in "Patient Expired"\r\n or IschemicStrokeEncounter.dischargeDisposition in "Discharged to Home for Hospice Care"\r\n or IschemicStrokeEncounter.dischargeDisposition in "Discharged to Health Care Facility for Hospice Care"\r\n )\r\n )\r\n
["Encounter, Performed": "Non-Elective Inpatient Encounter"] NonElectiveEncounter\r\n where Global."LengthInDays"(NonElectiveEncounter.relevantPeriod)%26lt;= 120\r\n and NonElectiveEncounter.relevantPeriod ends during "Measurement Period"\r\n
years between ToDate(BirthDateTime)and ToDate(AsOf)\r\n
Encounter Visit\r\n let ObsVisit: Last(["Encounter, Performed": "Observation Services"] LastObs\r\n where LastObs.relevantPeriod ends 1 hour or less on or before start of Visit.relevantPeriod\r\n sort by \r\n end of relevantPeriod\r\n ),\r\n VisitStart: Coalesce(start of ObsVisit.relevantPeriod, start of Visit.relevantPeriod),\r\n EDVisit: Last(["Encounter, Performed": "Emergency Department Visit"] LastED\r\n where LastED.relevantPeriod ends 1 hour or less on or before VisitStart\r\n sort by \r\n end of relevantPeriod\r\n )\r\n return Interval[Coalesce(start of EDVisit.relevantPeriod, VisitStart), \r\n end of Visit.relevantPeriod]\r\n
difference in days between start of Value and end of Value\r\n
DateTime(year from Value, month from Value, day from Value, 0, 0, 0, 0, timezone from Value)\r\n
["Patient Characteristic Ethnicity": "Ethnicity"]\r\n
["Patient Characteristic Payer": "Payer"]\r\n
["Patient Characteristic Race": "Race"]\r\n
["Patient Characteristic Sex": "ONC Administrative Sex"]\r\n
| Measure Set | \r\n\r\n | \r\n
| eCQM Title | \r\nDischarged on Statin Medication | \r\n ||
| eCQM Identifier (Measure Authoring Tool) | \r\n105 | \r\neCQM Version number | \r\n8.1.000 | \r\n
| NQF Number | \r\nNot Applicable | \r\nGUID | \r\n1f503318-bb8d-4b91-af63-223ae0a2328e | \r\n
| Measurement Period | \r\nJanuary 1, 20XX through December 31, 20XX | \r\n||
| Measure Steward | \r\nThe Joint Commission | \r\n||
| Measure Developer | \r\nThe Joint Commission | \r\n||
| Endorsed By | \r\nNone | \r\n||
| Description | \r\n\r\n | \r\n||
| Copyright | \r\n\r\n | \r\n||
| Disclaimer | \r\n\r\n | \r\n||
| Measure Scoring | \r\nProportion | \r\n||
| Measure Type | \r\nProcess | \r\n||
| Stratification | \r\n\r\n | \r\n||
| Risk Adjustment | \r\n\r\n | \r\n||
| Rate Aggregation | \r\n\r\n | \r\n||
| Rationale | \r\n\r\n | \r\n||
| Clinical Recommendation Statement | \r\n\r\n | \r\n||
| Improvement Notation | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Reference | \r\n\r\n | \r\n||
| Definition | \r\n\r\n | \r\n||
| Guidance | \r\n\r\n | \r\n||
| Transmission Format | \r\n\r\n | \r\n||
| Initial Population | \r\n\r\n | \r\n||
| Denominator | \r\n\r\n | \r\n||
| Denominator Exclusions | \r\n\r\n | \r\n||
| Numerator | \r\n\r\n | \r\n||
| Numerator Exclusions | \r\n\r\n | \r\n||
| Denominator Exceptions | \r\n\r\n | \r\n||
| Supplemental Data Elements | \r\n\r\n | \r\n
TJC."Encounter with Principal Diagnosis and Age"\r\n
TJC."Ischemic Stroke Encounter"\r\n
TJC."Ischemic Stroke Encounters with Discharge Disposition"\r\n union TJC."Comfort Measures during Hospitalization"\r\n
TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter\r\n with "Statin at Discharge" DischargeStatin\r\n such that DischargeStatin.authorDatetime during IschemicStrokeEncounter.relevantPeriod\r\n
( TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter\r\n with "Statin Not Given at Discharge" NoDischargeStatin\r\n such that NoDischargeStatin.authorDatetime during IschemicStrokeEncounter.relevantPeriod\r\n )\r\n union ( TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter\r\n with "Statin Allergy" StatinAllergy\r\n such that StatinAllergy.prevalencePeriod starts on or before end of IschemicStrokeEncounter.relevantPeriod\r\n )\r\n union "Encounter with Max LDL less than 70 mg per dL"\r\n
TJC."Ischemic Stroke Encounter"\r\n
( TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter\r\n with "Statin Not Given at Discharge" NoDischargeStatin\r\n such that NoDischargeStatin.authorDatetime during IschemicStrokeEncounter.relevantPeriod\r\n )\r\n union ( TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter\r\n with "Statin Allergy" StatinAllergy\r\n such that StatinAllergy.prevalencePeriod starts on or before end of IschemicStrokeEncounter.relevantPeriod\r\n )\r\n union "Encounter with Max LDL less than 70 mg per dL"\r\n
TJC."Ischemic Stroke Encounters with Discharge Disposition"\r\n union TJC."Comfort Measures during Hospitalization"\r\n
TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter\r\n where Max(["Laboratory Test, Performed": "LDL-c"] Ldl\r\n where Ldl.resultDatetime during Interval[Global."ToDate"(start of IschemicStrokeEncounter.relevantPeriod - 30 days), end of IschemicStrokeEncounter.relevantPeriod]\r\n return Ldl.result as Quantity\r\n )%26lt; 70 'mg/dL'\r\n
TJC."Encounter with Principal Diagnosis and Age"\r\n
TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter\r\n with "Statin at Discharge" DischargeStatin\r\n such that DischargeStatin.authorDatetime during IschemicStrokeEncounter.relevantPeriod\r\n
["Patient Characteristic Ethnicity": "Ethnicity"]\r\n
["Patient Characteristic Payer": "Payer"]\r\n
["Patient Characteristic Race": "Race"]\r\n
["Patient Characteristic Sex": "ONC Administrative Sex"]\r\n
["Allergy/Intolerance": "Statin Allergen"]\r\n
["Medication, Discharge": "Statin Grouper"]\r\n
["Medication, Not Discharged": "Statin Grouper"] NoStatinDischarge\r\n where NoStatinDischarge.negationRationale in "Medical Reason"\r\n or NoStatinDischarge.negationRationale in "Patient Refusal"\r\n
"Non Elective Inpatient Encounter" NonElectiveEncounter\r\n where NonElectiveEncounter.principalDiagnosis in "Hemorrhagic Stroke"\r\n or NonElectiveEncounter.principalDiagnosis in "Ischemic Stroke"\r\n
"Ischemic Stroke Encounter" IschemicStrokeEncounter\r\n with "Intervention Comfort Measures" ComfortMeasure\r\n such that Coalesce(start of ComfortMeasure.relevantPeriod, ComfortMeasure.authorDatetime)during Global."HospitalizationWithObservation"(IschemicStrokeEncounter)\r\n
"All Stroke Encounter" AllStrokeEncounter\r\n with ["Patient Characteristic Birthdate": "Birth date"] BirthDate\r\n such that Global."CalendarAgeInYearsAt"(BirthDate.birthDatetime, start of AllStrokeEncounter.relevantPeriod)%26gt;= 18\r\n
["Intervention, Order": "Comfort Measures"]\r\n union ["Intervention, Performed": "Comfort Measures"]\r\n
"Encounter with Principal Diagnosis and Age" EncounterWithAge\r\n where EncounterWithAge.principalDiagnosis in "Ischemic Stroke"\r\n
( ( "Ischemic Stroke Encounter" IschemicStrokeEncounter\r\n where IschemicStrokeEncounter.dischargeDisposition in "Discharge To Acute Care Facility"\r\n or IschemicStrokeEncounter.dischargeDisposition in "Left Against Medical Advice"\r\n or IschemicStrokeEncounter.dischargeDisposition in "Patient Expired"\r\n or IschemicStrokeEncounter.dischargeDisposition in "Discharged to Home for Hospice Care"\r\n or IschemicStrokeEncounter.dischargeDisposition in "Discharged to Health Care Facility for Hospice Care"\r\n )\r\n )\r\n
["Encounter, Performed": "Non-Elective Inpatient Encounter"] NonElectiveEncounter\r\n where Global."LengthInDays"(NonElectiveEncounter.relevantPeriod)%26lt;= 120\r\n and NonElectiveEncounter.relevantPeriod ends during "Measurement Period"\r\n
years between ToDate(BirthDateTime)and ToDate(AsOf)\r\n
Encounter Visit\r\n let ObsVisit: Last(["Encounter, Performed": "Observation Services"] LastObs\r\n where LastObs.relevantPeriod ends 1 hour or less on or before start of Visit.relevantPeriod\r\n sort by \r\n end of relevantPeriod\r\n ),\r\n VisitStart: Coalesce(start of ObsVisit.relevantPeriod, start of Visit.relevantPeriod),\r\n EDVisit: Last(["Encounter, Performed": "Emergency Department Visit"] LastED\r\n where LastED.relevantPeriod ends 1 hour or less on or before VisitStart\r\n sort by \r\n end of relevantPeriod\r\n )\r\n return Interval[Coalesce(start of EDVisit.relevantPeriod, VisitStart), \r\n end of Visit.relevantPeriod]\r\n
difference in days between start of Value and end of Value\r\n
DateTime(year from Value, month from Value, day from Value, 0, 0, 0, 0, timezone from Value)\r\n
["Patient Characteristic Ethnicity": "Ethnicity"]\r\n
["Patient Characteristic Payer": "Payer"]\r\n
["Patient Characteristic Race": "Race"]\r\n
["Patient Characteristic Sex": "ONC Administrative Sex"]\r\n
| Measure Set | \r\n\r\n | \r\n
| Measure Title | Discharged on Antithrombotic Therapy | Measure ID | EXM104 |
| Description | \n | \n||
| Measurement Period | \nJanuary 1 - December 31 | \n||
| Copyright and Disclaimer Notice | \n\n \n | \n||
| Clinical Recommendation Statement | \n\n \n | \n||
| References | \n\n \n | \n||
| \n \n | \n|||
| \n \n | \n|||
| \n \n | \n|||
| \n \n | \n|||
| \n \n | \n|||
| \n \n | \n|||
| \n \n | \n|||
| Characteristics | \n|||
| Scoring | \nProportion | \n||
| Type | \nProcess | \n||
| Improvement Notation | \nA higher rate indicates better performance. | \n \n||
| Guidance | \n\n \n | \n||
| Definitions | \n
| Id: | Measure/exm124-FHIR3 | ||||
|---|---|---|---|---|---|
| Type: | system: http://hl7.org/fhir/measure-type code: process | ||||
| Identifier: | system: http://hl7.org/fhir/cqi/ecqm/Measure/Identifier/cms value: 130 | ||||
| system: http://hl7.org/fhir/cqi/ecqm/Measure/Identifier/nqf value: 0034 | |||||
| Title: | Cervical Cancer Screening | ||||
| Status: | active | ||||
| Description: | Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria: <br> * Women age 21-64 who had cervical cytology performed every 3 years <br.* Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years | ||||
| Purpose: | Women 23-64 years of age with a visit during the measurement period | ||||
| Use Context: | code: program value: | ||||
| Topic: | system: http://loinc.org code: 57024-2 display: Health Quality Measure Document | ||||
| Contributor: | author: National Committee for Quality Assurance | ||||
| Related: | type: citation citation: | ||||
type: citation citation: | |||||
type: citation citation: | |||||
type: citation citation: | |||||
| Library: | reference: Library/exm124-FHIR3 | ||||
| Disclaimer: | The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. <br> Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM]. | ||||
| Scoring: | system: http://hl7.org/fhir/measure-scoring code: proportion | ||||
| Rationale: | Breast cancer is one of the most common types of cancers, accounting for 15 percent of all new cancer diagnoses in the U.S. (Howlader et al, 2016). In 2013, over 3 million women were estimated to be living with breast cancer in the U.S. and it is estimated that 12 percent of women will be diagnosed with breast cancer at some point during their lifetime (Howlader et al, 2016). <br> While there are other factors that affect a woman's risk of developing breast cancer, advancing age is a primary risk factor. Breast cancer is most frequently diagnosed among women ages 55-64; the median age at diagnosis is 62 years (Howlader et al, 2016). The chance of a woman being diagnosed with breast cancer in a given year increases with age. By age 40, the chances are 1 in 235; by age 50 it becomes 1 in 54; by age 60, it is 1 in 25 (National Business Group on Health, 2011). <br> In the U.S., costs associated with a diagnosis of breast cancer range from $451 to $2,520, factoring in continued testing, multiple office visits and procedures. The total costs related to breast cancer add up to nearly $7 billion per year in the U.S., including $2 billion spent on late-stage treatment (National Business Group on Health, 2011). If breast cancer is detected through mammography screening and diagnosed in its earliest stages, treatment may be less expensive (Feig, 2011). | ||||
| Clinical Recommendation: | The U.S. Preventive Services Task Force (USPSTF) recommends biennial screening mammography for women aged 50-74 years (B recommendation). <br> The decision to start screening mammography in women prior to age 50 years should be an individual one. Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years (C recommendation). (USPSTF, 2016) <br> The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women aged 75 years or older (I statement). (USPSTF, 2016) <br> The USPSTF concludes that the current evidence is insufficient to assess the benefits and harms of digital breast tomosynthesis (DBT) as a primary screening method for breast cancer (I Statement). (USPSTF, 2016) <br> The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, magnetic resonance imaging, DBT, or other methods in women identified to have dense breasts on an otherwise negative screening mammogram (I statement). (USPSTF, 2016) | ||||
| Guidance: | To ensure the measure is only looking for a cervical cytology test only after a woman turns 21 years of age, the youngest age in the initial population is 23. <br> Patient self-report for procedures as well as diagnostic studies should be recorded in 'Procedure, Performed' template or 'Diagnostic Study, Performed' template in QRDA-1. <br> Include only cytology and HPV "co-testing"; in co-testing, both cytology and HPV tests are performed (i.e., the samples are collected and both tests are ordered, regardless of the cytology result) on the same date of service. Do not include reflex testing. In addition, if the medical record indicates the HPV test was performed only after determining the cytology result, this is considered reflex testing and does not meet criteria for the measure. | ||||
| Group: | Identifier: | ||||
| |||||
| Supplemental Data: | Identifier: usage: criteria: SDE Ethnicity | ||||
Identifier: usage: criteria: SDE Payer | |||||
Identifier: usage: criteria: SDE Race | |||||
Identifier: usage: criteria: SDE Sex |