Meaningful Measures and Clinical Quality Measures...2 Meaningful Use Measures 2.1 Computerized Provider Order Entry (CPOE) Objective: Use computerized provider order entry for medication,

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Meaningful Measures and Clinical Quality Measures PowerServer RIS/PACS MU 6.0

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Meaningful Measures and Clinical Quality Measures

1 EXECUTIVE SUMMARY ............................................................................................................... 1 2 Meaningful Use Measures ............................................................................................................. 2 2.1 Computerized Provider Order Entry (CPOE) .......................................................................... 2

2.1.1 Definition ......................................................................................................................... 2 2.1.2 Calculations ..................................................................................................................... 2

2.2 Electronic Prescribing (eRx) ................................................................................................... 3


2.3 Health Information Exchange ................................................................................................. 4


2.4 Patient Specific Education ...................................................................................................... 5


2.5 Medication Reconciliation ....................................................................................................... 5 2.5.1 Definition ......................................................................................................................... 5 2.5.2 Calculations ..................................................................................................................... 6

2.6 Patient Electronic Access ....................................................................................................... 6


3 Clinical Quality Measures .............................................................................................................. 8

3.1 Closing the Referral Loop: Receipt of Specialist Report Population Criteria 1, Numerator 1 .. 8 3.1.1 Definition: ........................................................................................................................ 8

3.1.2 Calculations ..................................................................................................................... 8 3.2 Documentation of Current Medications in the Medical Record ............................................... 9

3.2.1 Definition: ........................................................................................................................ 9

3.2.2 Calculations ................................................................................................................... 10 3.3 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan .... 11

3.3.1 Definition: ...................................................................................................................... 11 3.3.2 Calculations ................................................................................................................... 15

3.4 Childhood Immunization Status ............................................................................................ 17 3.4.1 Definition: ...................................................................................................................... 17 3.4.2 Calculations ................................................................................................................... 27

3.5 Breast Cancer Screening ...................................................................................................... 31 3.5.1 Definition: ...................................................................................................................... 31

3.5.2 Calculations ................................................................................................................... 32 3.6 Pneumonia Vaccination Status for Older Adults ................................................................... 33

3.6.1 Definition: ...................................................................................................................... 33 3.6.2 Calculations ................................................................................................................... 33

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3.7 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention ....... 34 3.7.1 Definition: ...................................................................................................................... 34 3.7.2 Calculations ................................................................................................................... 35

3.8 Preventive Care and Screening: Influenza Immunization ..................................................... 36 3.8.1 Definition: ...................................................................................................................... 37 3.8.2 Calculations: .................................................................................................................. 39

3.9 Controlling High Blood Pressure ........................................................................................... 40 3.9.1 Definition: ...................................................................................................................... 40

3.9.2 Calculations: .................................................................................................................. 41 3.10 Use of Imaging Studies for Low Back Pain ........................................................................... 42

3.10.1 Definition: ...................................................................................................................... 43

3.10.2 Calculations: .................................................................................................................. 44 4 REFERENCES ............................................................................................................................ 45

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1 EXECUTIVE SUMMARY

This document provides the details on how Meaningful Use Measures and Clinical Quality Measures are calculated in RamSoft PowerServer.

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2 Meaningful Use Measures

2.1 Computerized Provider Order Entry (CPOE)

Objective: Use computerized provider order entry for medication, laboratory, and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local, and professional guidelines.

2.1.1 Definition

2.1.1.1 Medication:

Title: Percentage of Medication orders created by the EP during the EHR reporting period are recorded using computerized provider order entry.

Denominator: Number of medication orders created by the EP during the EHR reporting period. Numerator: The number of orders in the denominator recorded using CPOE.

2.1.1.2 Laboratory:

Title: Percentage of Laboratory orders created by the EP during the EHR reporting period are recorded using computerized provider order entry. Denominator: Number of laboratory orders created by the EP during the EHR reporting period. Numerator: The number of orders in the denominator recorded using CPOE.

2.1.1.3 Radiology:

Title: Percentage of Radiology orders created by the EP during the EHR reporting period are recorded using computerized provider order entry. Denominator: Number of radiology orders created by the EP during the EHR reporting period. Numerator: The number of orders in the denominator recorded using CPOE.

2.1.2 Calculations

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2.1.2.1 Medication:

Denominator: Number of medication order of the patients with the given Issuer(s) of Patient ID and for the given facilities who the provider (EP) has read at least one study within the reporting period. Numerator: We provide CPOE for the each patient, so numerator will always be equal to denominator. Note: The medications enter on the med entry screen will not be included in the denominator This measure will always have the performance percentage as 100%.

2.1.2.2 Laboratory:

Denominator: Number of lab order of the patients with the given Issuer(s) of Patient ID and for the given facilities who the provider (EP) has read at least one study within the reporting period. Numerator: We provide CPOE for the each patient, so numerator will always be equal to denominator. This measure will always have the performance percentage as 100%.

2.1.2.3 Radiology:

Denominator: Number of Radiology order (Study) ordered from RapidResults of the patients with the given Issuer(s) of Patient ID and for the given facilities who the provider (EP) is the referring physician within the reporting period. Numerator: We provide CPOE for the each patient, so numerator will always be equal to denominator. This measure will always have the performance percentage as 100%. 2.2 Electronic Prescribing (eRx)

Objective: Generate and transmit permissible prescriptions electronically (eRx).

2.2.1 Definition

Title: Percentage of all permissible prescriptions written by the EP are queried for a drug formulary and transmitted electronically using CEHRT.

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Denominator: Number of permissible prescriptions written during the EHR reporting period for drugs requiring a prescription in order to be dispensed. Numerator: The number of prescriptions in the denominator generated, queried for a drug formulary and transmitted electronically using CEHRT.

2.2.2 Calculations

Denominator: Number of medications of patients with the given Issuer(s) of Patient ID and for the given Facilities which the provider (EP) has prescribed within the reporting period and has final destination type not equal to ‘0’. Numerator: Number of prescriptions in the denominator with final destination type is 3 or 4. Note: 1. Final Destination Type value of 3 or 4, indicates the prescription was sent electronically. 2. Final Destination Type value of 0, indicates that it is not prescription but a med entry. 3. Permissible Prescriptions - may include or not include controlled substances based on provider selection

and where allowable by state and local law.

2.3 Health Information Exchange

Objective: The EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care provides a summary care record for each transition of care or referral. 2.3.1 Definition

Title: The EP that transitions or refers their patient to another setting of care or provider of care must (1) use CEHRT to create summary of care records; and (2) electronically transmit such summaries to receiving providers for percentage of transitions of care and referrals. Denominator: Number of transitions of care and referrals during the EHR reporting period for which the EP was the transferring or referring provider. Numerator: The number of transitions of care and referrals in the denominator where a summary of care record was created using CEHRT and exchanged electronically. 2.3.2 Calculations

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Denominator: Number of studies which are created from messaging using convert to appointment of patients with the given Issuer(s) of Patient ID and for the given Facilities who the provider (EP) is the referring physician. Numerator: Number of studies in the denominator which at least one summary (CCDA) has been sent. 2.4 Patient Specific Education

Objective: Use clinically relevant information from CEHRT to identify patient-specific education resources and provide those resources to the patient. 2.4.1 Definition

Title: Patient-specific education resources identified by CEHRT that are provided to patients for percentage of unique patients with office visits seen by the EP during the EHR reporting period. Denominator: Number of unique patients with office visits seen by the EP during the EHR reporting period. Numerator: Number of patients in the denominator who were provided patient-specific education resources identified by the CEHRT. 2.4.2 Calculations

Denominator: Number of unique patients with at least one study with at least one procedure with procedure

code that is marked as “Office Visit” and "Seen by Physician" in the Procedure Codes table with the given Issuer(s) of Patient ID and for the given Facilities who the provider (EP) has read at least one study within the reporting period. Numerator: Number of patients in the denominator for which the education resource has been provided. Note: Patient Education Resource can be accessed by clicking the Education Resource button in Study Info screen, Lab Results screen or Patient Leaflet in medication screen or by having Education Resource URL bookmark on the report that has been distributed. 2.5 Medication Reconciliation

Objective: The EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation.

2.5.1 Definition

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Title: The EP performs medication reconciliation for percentage of transitions of care in which the patient is transitioned into the care of the EP. Denominator: Number of transitions of care during the EHR reporting period for which the EP was the receiving party of the transition. Numerator: The number of transitions of care in the denominator where medication reconciliation was performed. 2.5.2 Calculations

Denominator: Number of visits of with the given Issuer(s) of Patient ID and for the given Facilities who the provider (EP) has read at least one study within the reporting period and the referring physician of the study is recorded and referring physician is not equal to reading physician and the imaging facility is not equal to referring facility. Numerator: Number of visits in the denominator for which the medication has been reconciled. Note: Since we set the default value as ‘Takes No Medication’ for new patients. It is considered as reconciled which is automatic. In the case when we import the CCDA with medication, we add the medication(s) as imported medication and user need to go NewCrop screen in order to reconcile those medications. And when user goes to the NewCrop screen these medications are shown as imported medication but when user comes out of NewCrop screen we remove the imported medications from our database and assume that it is reconciled. 2.6 Patient Electronic Access

Objective: Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available to the EP.

2.6.1 Definition

2.6.1.1 Measure A:

Title: Percentage of all unique patients seen by the EP during the EHR reporting period are provided timely access to view online, download, and transmit to a third party their health information subject to the EP's discretion to withhold certain information. Denominator: Number of unique patients seen by the EP during the EHR reporting period.

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Numerator: The number of patients in the denominator who have access to view online, download and transmit their health information within 4 business days after the information is available to the EP.

2.6.1.2 Measure B:

Title: For an EHR reporting period in 2015, at least one patient seen by the EP during the EHR reporting period (or patient-authorized representative) views, downloads or transmits his or her health information to a third party during the EHR reporting period. Denominator: Number of unique patients seen by the EP during the EHR reporting period. Numerator: The number of patients in the denominator (or patient-authorized representative) who view, download, or transmit to a third party their health information.

2.6.2 Calculations

2.6.2.1 Measure A:

Denominator: Number of unique patients with at least one procedure with procedure code that is marked as

"Seen by Physician" in the Procedure Codes table with the given Issuer(s) of Patient ID and for the given Facilities who the provider (EP) has read at least one study within the reporting period. Numerator: Number of patients in the denominator for which the CCDA has been generated and attempted at least once to upload to the patient’s HealthVault account within 4 business days of the study date.

2.6.2.2 Measure B:

Denominator: Number of unique patients with at least one procedure with procedure code that is marked as

"Seen by Physician" in the Procedure Codes table with the given Issuer(s) of Patient ID and for the given Facilities who the provider (EP) has read at least one study within the reporting period. Numerator: Number of patients in the denominator for which the CCDA uploaded has been viewed, downloaded or transmitted on the patient’s HealthVault account.

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3 Clinical Quality Measures

3.1 Closing the Referral Loop: Receipt of Specialist Report Population Criteria 1, Numerator 1 Measure Identifier: CMS50 Version: 3 Description: Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred. 3.1.1 Definition:

Initial Patient Population: 1. AND: "Occurrence A of Intervention, Performed: Referral" during "Measurement Period" 2. AND:

OR: "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" OR: "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" OR: "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" OR: "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" OR: "Encounter, Performed: Office Visit" OR: "Encounter, Performed: Face-to-Face Interaction" During "Measurement Period"

Denominator: 1. AND: "Initial Patient Population";

Numerator:

1. AND: "Occurrence A of Intervention, Performed: Referral" ends before start of ("Occurrence A of

Communication: From Provider to Provider: Consultant Report" during "Measurement Period") 3.1.2 Calculations Initial Patient Population: Number of unique patients of any age with the given Issuer(s) of Patient ID and for the given Facilities who has at least one problem with a problem code name that matches in the MUVALUESET table with a set name ‘REFERRAL’ and with the problem date within the reporting period. Denominator: Number of unique patients of any age with the given Issuer(s) of Patient ID and for the given Facilities who has at least one problem with a problem code name that matches the MUVALUESET of the given

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CMSID with SETTYPE 'INTERVENTION' and CODESYSTEM = 'SNOMEDCT' with a SETNAME ‘REFERRAL’ and with the problem date within the reporting period. Numerator: Number of patients in the denominator who have at least one study with at least one procedure with code name that matches the MUVALUESET for the given CMSID with SETTYPE = 'ENCOUNTER' AND CODESYSTEM = 'CPT' and SETNAME IN ('OFFICE VISIT', 'PREVENTIVE CARE- INITIAL OFFICE VISIT, 0 TO 17', 'PREVENTIVE CARE - ESTABLISHED OFFICE VISIT, 0 TO 17', 'PREVENTIVE CARE SERVICES-INITIAL OFFICE VISIT, 18 AND UP', 'PREVENTIVE CARE SERVICES - ESTABLISHED OFFICE VISIT, 18 AND UP' and with the study date within the reporting period (or) with at least one problem with code name that matches the MUVALUESET for the given CMSID with SETTYPE = 'ENCOUNTER' AND CODESYSTEM = 'SNOMEDCT' AND SETNAME = 'FACE-TO-FACE INTERACTION' and with the problem date within the reporting period. 3.2 Documentation of Current Medications in the Medical Record Measure Identifier: 68 Version: 4 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. 3.2.1 Definition:

Initial Patient Population: All visits occurring during the 12 month reporting period for patients aged 18 years and older before the start of the measurement period 1. AND: "Patient Characteristic Birthdate: birth date" >= 18 year(s) starts before start of "Measurement

Period" 2. AND: "Occurrence A of Encounter, Performed: Medications Encounter Code Set" during "Measurement

Period" Denominator:

Equals Initial Patient Populations. Denominator Exclusions: None

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Numerator: 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

1. AND: "Procedure, Performed not done: Medical or Other reason not done" for "Current Medications

Documented SNMD " during "Occurrence A of Encounter, Performed: Medications Encounter Code Set" Denominator Exceptions:

Medical Reason: Patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status”

1. AND: "Procedure, Performed not done: Medical or Other reason not done" for "Current Medications Documented SNMD " during "Occurrence A of Encounter, Performed: Medications Encounter Code Set"

3.2.2 Calculations Initial Patient Population: Number of unique patients of age >= 18 before the measurement period with the given Issuer(s) of Patient ID and for the given Facilities who has at least one study a procedure with a procedure code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'ENCOUNTER' AND CODESYSTEM = 'CPT' and SETNAME = 'MEDICATIONS ENCOUNTER CODE SET' and with the study date within the reporting period. Denominator: Same as initial patient population. Numerator: Number of patients in the denominator who have at least one problem with code name that matches the MUVALUESET for the given CMSID with SETTYPE = 'PROCEDURE' AND CODESYSTEM = 'SNOMEDCT' AND SETNAME = 'CURRENT MEDICATIONS DOCUMENTED SNMD' and with the problem date within the reporting period. Denominator Exceptions: Number of patients in the denominator who have at least one problem with code name that matches the MUVALUESET for the given CMSID with SETTYPE = 'PROCEDURE' AND CODESYSTEM = 'SNOMEDCT' AND SETNAME = 'CURRENT MEDICATIONS DOCUMENTED SNMD' and ‘MEDICAL OR OTHER REASON NOT DONE’and with the problem date within the reporting period.

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3.3 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

Measure Identifier: CMS69 Version: 3

Description: Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter Normal Parameters: Age 65 years and older BMI => 23 and < 30 kg/m2 Age 18 – 64 years BMI => 18.5 and < 25 kg/m2 3.3.1 Definition:

3.3.1.1 Population Criteria 1:

Initial Patient Population1: All patients 18 through 64 years on the date of the encounter with at least one eligible encounter during the measurement period NOT INCLUDING encounters where the patient is receiving palliative care, refuses measurement of height and/or weight, the patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status, or there is any other reason documented in the medical record by the provider explaining why BMI measurement was not appropriate.

1. AND: "Patient Characteristic Birthdate: birth date" >= 18 year(s) starts before start of "Occurrence A of

Encounter, Performed: BMI Encounter Code Set" 2. AND: "Patient Characteristic Birthdate: birth date" <= 64 year(s) starts before start of "Occurrence A of

Encounter, Performed: BMI Encounter Code Set" 3. AND: "Occurrence A of Encounter, Performed: BMI Encounter Code Set" during "Measurement Period" 4. AND NOT:

a. OR: "Procedure, Order: Palliative Care" starts before or during "Occurrence A of Encounter, Performed: BMI Encounter Code Set"

b. OR: "Physical Exam, Performed not done: Medical or Other reason not done" for "BMI LOINC Value " during "Occurrence A of Encounter, Performed: BMI Encounter Code Set"

c. OR: "Physical Exam, Performed not done: Patient Reason Refused" for "BMI LOINC Value " during "Occurrence A of Encounter, Performed: BMI Encounter Code Set"

Denominator1:

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1. AND: “ All patients in the initial patient population’; Denominator Exclusions 1: 1. AND NOT: "Occurrence A of Diagnosis, Active: Pregnancy Dx" ends before start of "Measurement Period" 2. AND: "Occurrence A of Diagnosis, Active: Pregnancy Dx" starts before or during "Measurement Period"

Numerator1:

1. AND:

a. OR: i. AND: "Occurrence A of Physical Exam, Finding: BMI LOINC Value (result >= 18.5 kg/m2)" ii. AND: "Occurrence A of Physical Exam, Finding: BMI LOINC Value (result < 25 kg/m2)" iii. AND: MOST RECENT: "Occurrence A of Physical Exam, Finding: BMI LOINC Value" <= 6 month(s)

starts before or during "Occurrence A of Encounter, Performed: BMI Encounter Code Set" b. OR:

i. AND: OR: "Intervention, Order: Above Normal Follow-up (reason: 'Overweight')" <= 6 month(s) starts before or during "Occurrence A of Encounter, Performed: BMI Encounter Code Set" OR: "Intervention, Order: Referrals where weight assessment may occur (reason: 'Overweight')" <= 6 month(s) starts before or during "Occurrence A of Encounter, Performed: BMI Encounter Code Set" OR: "Medication, Order: Above Normal Medications (reason: 'Overweight')" <= 6 month(s) starts before or during "Occurrence A of Encounter, Performed: BMI Encounter Code Set"

ii. AND: "Occurrence A of Physical Exam, Finding: BMI LOINC Value (result >= 25 kg/m2)" iii. AND: MOST RECENT: "Occurrence A of Physical Exam, Finding: BMI LOINC Value" <= 6 month(s)

starts before or during "Occurrence A of Encounter, Performed: BMI Encounter Code Set" c. OR:

i. AND: OR: "Intervention, Order: Below Normal Follow up (reason: 'Underweight')" <= 6 month(s) starts before or during "Occurrence A of Encounter, Performed: BMI Encounter Code Set" OR: "Intervention, Order: Referrals where weight assessment may occur (reason: 'Underweight')" <= 6 month(s) starts before or during "Occurrence A of Encounter, Performed: BMI Encounter Code Set" OR: "Medication, Order: Below Normal Medications (reason: 'Underweight')" <= 6 month(s) starts before or during "Occurrence A of Encounter, Performed: BMI Encounter Code Set"

ii. AND: "Occurrence A of Physical Exam, Finding: BMI LOINC Value (result < 18.5 kg/m2)" iii. AND: MOST RECENT: "Occurrence A of Physical Exam, Finding: BMI LOINC Value" <= 6 month(s)

starts before or during "Occurrence A of Encounter, Performed: BMI Encounter Code Set"

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Initial Patient Population2:

1. AND: "Patient Characteristic Birthdate: birth date" >= 65 year(s) starts before start of "Occurrence A of Encounter, Performed: BMI Encounter Code Set"

2. AND: "Occurrence A of Encounter, Performed: BMI Encounter Code Set" during "Measurement Period" 3. AND NOT:

a. OR: "Procedure, Order: Palliative Care" starts before or during "Occurrence A of Encounter, Performed: BMI Encounter Code Set"

b. OR: "Physical Exam, Performed not done: Medical or Other reason not done" for "BMI LOINC Value " during "Occurrence A of Encounter, Performed: BMI Encounter Code Set"

c. OR: "Physical Exam, Performed not done: Patient Reason Refused" for "BMI LOINC Value " during "Occurrence A of Encounter, Performed: BMI Encounter Code Set"

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Denominator2:

1. AND NOT: "Occurrence A of Diagnosis, Active: Pregnancy Dx" ends before start of "Measurement Period"

2. AND: "Occurrence A of Diagnosis, Active: Pregnancy Dx" starts before or during "Measurement Period""

Denominator Exclusions 2:

1. AND: "Initial Patient Population 2" Numerator2:

1. AND: a. OR:

i. AND: MOST RECENT:"Occurrence A of Physical Exam, Finding: BMI LOINC Value" <= 6 month(s) starts before or during "Occurrence A of Encounter, Performed: BMI Encounter Code Set"

ii. AND: "Occurrence A of Physical Exam, Finding: BMI LOINC Value (result >= 23 kg/m2)" iii. AND: "Occurrence A of Physical Exam, Finding: BMI LOINC Value (result < 30 kg/m2)"

b. OR: i. AND:

OR: "Intervention, Order: Above Normal Follow-up (reason: 'Overweight')" <= 6 month(s) starts before or during "Occurrence A of Encounter, Performed: BMI Encounter Code Set" OR: "Intervention, Order: Referrals where weight assessment may occur (reason: 'Overweight')" <= 6 month(s) starts before or during "Occurrence A of Encounter, Performed: BMI Encounter Code Set" OR: "Medication, Order: Above Normal Medications (reason: 'Overweight')" <= 6 month(s) starts before or during "Occurrence A of Encounter, Performed: BMI Encounter Code Set"

ii. AND: "Occurrence A of Physical Exam, Finding: BMI LOINC Value (result >= 30 kg/m2)" iii. AND: MOST RECENT:"Occurrence A of Physical Exam, Finding: BMI LOINC Value" <= 6

month(s) starts before or during "Occurrence A of Encounter, Performed: BMI Encounter Code Set"

c. OR: i. AND:

OR: "Intervention, Order: Below Normal Follow up (reason: 'Underweight')" <= 6 month(s) starts before or during "Occurrence A of Encounter, Performed: BMI Encounter Code Set"

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OR: "Intervention, Order: Referrals where weight assessment may occur (reason: 'Underweight')" <= 6 month(s) starts before or during "Occurrence A of Encounter, Performed: BMI Encounter Code Set" OR: "Medication, Order: Below Normal Medications (reason: 'Underweight')" <= 6 month(s) starts before or during "Occurrence A of Encounter, Performed: BMI Encounter Code Set"

ii. AND: "Occurrence A of Physical Exam, Finding: BMI LOINC Value (result < 23 kg/m2)" iii. AND: MOST RECENT:"Occurrence A of Physical Exam, Finding: BMI LOINC Value" <= 6

month(s) starts before or during "Occurrence A of Encounter, Performed: BMI Encounter Code Set

3.3.2 Calculations


Initial Patient Population1: Number of unique patients of age >= 18 and age <= 64 years before the study date period with the given Issuer(s) of Patient ID and for the given Facilities who has at least one study a procedure with a procedure code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'ENCOUNTER' AND CODESYSTEM = 'CPT' and SETNAME = 'BMI ENCOUNTER CODE SET' and with the study date within the reporting period and without a study with a diagnosis with code name that matches in the MUVALUESET for the given CMSID with SETTYPE = ‘PROCEDURE’ AND CODESYSTEM IN ( ‘ICD10CM’, ‘ICD9CM’) and SETNAME= ‘PALLIATIVE CARE’ and also without a study a problem of code name that matches in the MUVALUESET for the given CMSID with SETTYPE = ‘ATTRIBUTE’ and CODESYSTEM=’SNOMEDCT’ and SETNAME IN (MEDICAL OR OTHER REASON NOT DONE','PATIENT REASON REFUSED') where the problem date is within the study date. Denominator1: Same as Initial Patient Population1 Denominator Exclusions 1: Patients with study with a diagnosis of code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM' AND CODESYSTEM IN ('ICD10CM','ICD9CM') AND SETNAME = 'PREGNANCY DX' Numerator1: Number of patients in the denominator who has a lab result with a code ‘39156-5’(BMI) and the most resent order date is within six months prior to the study date and the result is >= 18.5 KG/M2 and < 25. Or the result is >= 25 and the patient has a problem with code name that matches in the MUVALUESET of the given CMSID with SETTYPE = ' INTERVENTION' AND CODESYSTEM = 'SNOMEDCT' AND SETNAME IN ('ABOVE

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NORMAL FOLLOW-UP', 'REFERRALS WHERE WEIGHT ASSESSMENT MAY OCCUR') with a problem date within six months prior to the study date. Or the result is < 18.5 and the patient has a problem with code name that matches in the MUVALUESET of the given CMSID with SETTYPE = ' INTERVENTION' AND CODESYSTEM = 'SNOMEDCT' AND SETNAME IN ('BELOW NORMAL FOLLOW UP', 'REFERRALS WHERE WEIGHT ASSESSMENT MAY OCCUR') with a problem date within six months prior to the study date


Initial Patient Population2: Number of unique patients of age >= 65 based on the study date with the given Issuer(s) of Patient ID and for the given Facilities who has at least one study a procedure with a procedure code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'ENCOUNTER' AND CODESYSTEM = 'CPT' and SETNAME = 'BMI ENCOUNTER CODE SET' and with the study date within the reporting period and without a study with a diagnosis with code name that matches in the MUVALUESET for the given CMSID with SETTYPE = ‘PROCEDURE’ AND CODESYSTEM IN ( ‘ICD10CM’, ‘ICD9CM’) and SETNAME= ‘PALLIATIVE CARE’ and also without a study a problem of code name that matches in the MUVALUESET for the given CMSID with SETTYPE = ‘ATTRIBUTE’ and CODESYSTEM=’SNOMEDCT’ and SETNAME IN (MEDICAL OR OTHER REASON NOT DONE','PATIENT REASON REFUSED') where the problem date is within the study date. Denominator2: Same as Initial Patient Population2 Denominator Exclusions 2: Patients with study with a diagnosis of code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM' AND CODESYSTEM IN ('ICD10CM','ICD9CM') AND SETNAME = 'PREGNANCY DX' Numerator2: Number of patients in the denominator who has a lab result with a code ‘39156-5’(BMI) and the most resent order date is within six months prior to the study date and the result is >= 23 KG/M2 and < 30. Or the result is >= 30 and the patient has a problem with code name that matches in the MUVALUESET of the given CMSID with SETTYPE = ' INTERVENTION' AND CODESYSTEM = 'SNOMEDCT' AND SETNAME IN ('ABOVE NORMAL FOLLOW-UP', 'REFERRALS WHERE WEIGHT ASSESSMENT MAY OCCUR') with a problem date within six months prior to the study date. Or the result is < 23 and the patient has a problem with code name that matches in the MUVALUESET of the given CMSID with SETTYPE = ' INTERVENTION' AND CODESYSTEM = 'SNOMEDCT' AND SETNAME IN ('BELOW NORMAL FOLLOW UP', 'REFERRALS WHERE WEIGHT ASSESSMENT MAY OCCUR') with a problem date within six months prior to the study date

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3.4 Childhood Immunization Status

Measure Identifier: 117 Version: 3 Description: Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday.

3.4.1 Definition: Initial Patient Population:

1. AND: "Patient Characteristic Birthdate: birth date" >= 1 year(s) starts before start of "Measurement

Period" 2. AND: "Patient Characteristic Birthdate: birth date" = 2 year(s) starts before start of "Measurement

End Date" 3. AND:

a. OR: "Encounter, Performed: Office Visit" b. OR: "Encounter, Performed: Face-to-Face Interaction" c. OR: "Encounter, Performed: Home Healthcare Services" d. OR: "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" e. OR: "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" f. during "Measurement Period"

Denominator: AND: "Initial Patient Population" Numerator:

1. AND: a. OR:

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AND: "Occurrence D of Medication, Administered: DTaP Vaccine" >= 1 day(s) starts after end of ("Occurrence C of Medication, Administered: DTaP Vaccine" >= 1 day(s) starts after end of ("Occurrence B of Medication, Administered: DTaP Vaccine" >= 1 day(s) starts after end of "Occurrence A of Medication, Administered: DTaP Vaccine"))

AND: "Occurrence A of Medication, Administered: DTaP Vaccine" >= 42 day(s) ends after start of "Patient Characteristic Birthdate: birth date" AND:

AND: "Occurrence A of Medication, Administered: DTaP Vaccine" AND: "Occurrence B of Medication, Administered: DTaP Vaccine" AND: "Occurrence C of Medication, Administered: DTaP Vaccine" AND: "Occurrence D of Medication, Administered: DTaP Vaccine" <= 730 day(s) ends after start of "Patient Characteristic Birthdate: birth date"

b. OR: AND: "Occurrence D of Procedure, Performed: DTaP Vaccine Administered" >= 1 day(s) starts after end of ("Occurrence C of Procedure, Performed: DTaP Vaccine Administered" >= 1 day(s) starts after end of ("Occurrence B of Procedure, Performed: DTaP Vaccine Administered" >= 1 day(s) starts after end of "Occurrence A of Procedure, Performed: DTaP Vaccine Administered")) AND: "Occurrence A of Procedure, Performed: DTaP Vaccine Administered" >= 42 day(s) ends after start of "Patient Characteristic Birthdate: birth date" AND:

AND: "Occurrence A of Procedure, Performed: DTaP Vaccine Administered" AND: "Occurrence B of Procedure, Performed: DTaP Vaccine Administered" AND: "Occurrence C of Procedure, Performed: DTaP Vaccine Administered" AND: "Occurrence D of Procedure, Performed: DTaP Vaccine Administered" <= 730 day(s) ends after start of "Patient Characteristic Birthdate: birth date"

c. OR: OR: "Diagnosis, Active: Anaphylactic Reaction to DTaP Vaccine" OR: "Diagnosis, Active: Encephalopathy" OR: "Diagnosis, Resolved: Encephalopathy" <= 730 day(s) starts after start of "Patient Characteristic Birthdate: birth date"

2. AND: a. OR:

AND: "Occurrence C of Medication, Administered: Inactivated Polio Vaccine (IPV)" >= 1 day(s) starts after end of ("Occurrence B of Medication, Administered: Inactivated Polio Vaccine (IPV)" >= 1 day(s) starts after end of "Occurrence A of Medication, Administered: Inactivated Polio Vaccine (IPV)") AND: "Occurrence A of Medication, Administered: Inactivated Polio Vaccine (IPV)" >= 42 day(s) ends after start of "Patient Characteristic Birthdate: birth date" AND:

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AND: "Occurrence A of Medication, Administered: Inactivated Polio Vaccine (IPV)" AND: "Occurrence B of Medication, Administered: Inactivated Polio Vaccine (IPV)" AND: "Occurrence C of Medication, Administered: Inactivated Polio Vaccine (IPV)" <= 730 day(s) ends after start of "Patient Characteristic Birthdate: birth date"

b. OR: AND: "Occurrence C of Procedure, Performed: Inactivated Polio Vaccine (IPV) Administered" >= 1 day(s) starts after end of ("Occurrence B of Procedure, Performed: Inactivated Polio Vaccine (IPV) Administered" >= 1 day(s) starts after end of "Occurrence A of Procedure, Performed: Inactivated Polio Vaccine (IPV) Administered") AND: "Occurrence A of Procedure, Performed: Inactivated Polio Vaccine (IPV) Administered" >= 42 day(s) ends after start of "Patient Characteristic Birthdate: birth date" AND:

AND: "Occurrence A of Procedure, Performed: Inactivated Polio Vaccine (IPV) Administered" AND: "Occurrence B of Procedure, Performed: Inactivated Polio Vaccine (IPV) Administered" AND: "Occurrence C of Procedure, Performed: Inactivated Polio Vaccine (IPV) Administered" <= 730 day(s) ends after start of "Patient Characteristic Birthdate: birth date"

c. OR: OR: "Diagnosis, Active: Anaphylactic Reaction to Inactivated Polio Vaccine (IPV)" OR: "Diagnosis, Active: Anaphylactic Reaction to Streptomycin" OR: "Diagnosis, Active: Anaphylactic Reaction to Polymyxin" OR: "Diagnosis, Active: Anaphylactic Reaction to Neomycin" <= 730 day(s) starts after start of "Patient Characteristic Birthdate: birth date"

3. AND: a. OR:

OR: "Medication, Administered: Measles, Mumps and Rubella (MMR) Vaccine" OR: "Procedure, Performed: Measles, Mumps and Rubella (MMR) Vaccine Administered" <= 730 day(s) ends after start of "Patient Characteristic Birthdate: birth date"

b. OR: OR: "Diagnosis, Active: Disorders of the Immune System" OR: "Diagnosis, Active: HIV" OR: "Diagnosis, Active: Malignant Neoplasm of Lymphatic and Hematopietic Tissue" OR: "Diagnosis, Active: Anaphylactic Reaction to Neomycin" OR:

AND: OR: "Diagnosis, Active: Measles" OR: "Diagnosis, Resolved: Measles"

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OR: "Laboratory Test, Result: Measles Antigen Test (result: 'Seropositive')"

AND: OR: "Diagnosis, Active: Mumps" OR: "Diagnosis, Resolved: Mumps" OR: "Laboratory Test, Result: Mumps Antigen Test (result: 'Seropositive')"

AND: OR: "Diagnosis, Active: Rubella" OR: "Diagnosis, Resolved: Rubella" OR: "Laboratory Test, Result: Rubella Antigen Test (result: 'Seropositive')"

<= 730 day(s) starts after start of "Patient Characteristic Birthdate: birth date" 4. AND:

a. OR: "Diagnosis, Active: Anaphylactic Reaction to Hemophilus Influenza B (HiB) Vaccine" <= 730 day(s) starts after start of "Patient Characteristic Birthdate: birth date"

b. OR: AND: "Occurrence C of Medication, Administered: Hemophilus Influenze B (HiB) Vaccine" >= 1 day(s) starts after end of ("Occurrence B of Medication, Administered: Hemophilus Influenze B (HiB) Vaccine" >= 1 day(s) starts after end of "Occurrence A of Medication, Administered: Hemophilus Influenze B (HiB) Vaccine") AND: "Occurrence A of Medication, Administered: Hemophilus Influenze B (HiB) Vaccine" >= 42 day(s) ends after start of "Patient Characteristic Birthdate: birth date" AND:

AND: "Occurrence A of Medication, Administered: Hemophilus Influenze B (HiB) Vaccine" AND: "Occurrence B of Medication, Administered: Hemophilus Influenze B (HiB) Vaccine" AND: "Occurrence C of Medication, Administered: Hemophilus Influenze B (HiB) Vaccine" <= 730 day(s) ends after start of "Patient Characteristic Birthdate: birth date"

c. OR: AND: "Occurrence C of Procedure, Performed: Hemophilus Influenze B (HiB) Vaccine Administered" >= 1 day(s) starts after end of ("Occurrence B of Procedure, Performed: Hemophilus Influenze B (HiB) Vaccine Administered" >= 1 day(s) starts after end of "Occurrence A of Procedure, Performed: Hemophilus Influenze B (HiB) Vaccine Administered") AND: "Occurrence A of Procedure, Performed: Hemophilus Influenze B (HiB) Vaccine Administered" >= 42 day(s) ends after start of "Patient Characteristic Birthdate: birth date" AND:

AND: "Occurrence A of Procedure, Performed: Hemophilus Influenze B (HiB) Vaccine Administered"

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AND: "Occurrence B of Procedure, Performed: Hemophilus Influenze B (HiB) Vaccine Administered" AND: "Occurrence C of Procedure, Performed: Hemophilus Influenze B (HiB) Vaccine Administered" <= 730 day(s) ends after start of "Patient Characteristic Birthdate: birth date"

5. AND: a. OR:

AND: "Occurrence C of Medication, Administered: Hepatitis B Vaccine" >= 1 day(s) starts after end of ("Occurrence B of Medication, Administered: Hepatitis B Vaccine" >= 1 day(s) starts after end of "Occurrence A of Medication, Administered: Hepatitis B Vaccine") AND:

AND: "Occurrence A of Medication, Administered: Hepatitis B Vaccine" AND: "Occurrence B of Medication, Administered: Hepatitis B Vaccine" AND: "Occurrence C of Medication, Administered: Hepatitis B Vaccine" <= 730 day(s) ends after start of "Patient Characteristic Birthdate: birth date"

b. OR: AND: "Occurrence C of Procedure, Performed: Hepatitis B Vaccine Administered" >= 1 day(s) starts after end of ("Occurrence B of Procedure, Performed: Hepatitis B Vaccine Administered" >= 1 day(s) starts after end of "Occurrence A of Procedure, Performed: Hepatitis B Vaccine Administered") AND:

AND: "Occurrence A of Procedure, Performed: Hepatitis B Vaccine Administered" AND: "Occurrence B of Procedure, Performed: Hepatitis B Vaccine Administered" AND: "Occurrence C of Procedure, Performed: Hepatitis B Vaccine Administered" <= 730 day(s) ends after start of "Patient Characteristic Birthdate: birth date"

c. OR: OR: "Diagnosis, Active: Anaphylactic Reaction to Hepatitis B Vaccine" OR: "Diagnosis, Active: Anaphylactic Reaction to Common Baker's Yeast" OR: "Diagnosis, Active: Hepatitis B" OR: "Diagnosis, Inactive: Hepatitis B" OR: "Laboratory Test, Result: Hepatitis B Antigen Test (result: 'Seropositive')" <= 730 day(s) starts after start of "Patient Characteristic Birthdate: birth date"

6. AND: a. OR:

OR: "Medication, Administered: Varicella Zoster Vaccine (VZV)" OR: "Procedure, Performed: Varicella Zoster Vaccine (VZV) Administered" <= 730 day(s) ends after start of "Patient Characteristic Birthdate: birth date"

b. OR: OR: "Diagnosis, Active: Disorders of the Immune System" OR: "Diagnosis, Active: HIV"

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OR: "Diagnosis, Active: Malignant Neoplasm of Lymphatic and Hematopietic Tissue" OR: "Diagnosis, Active: Anaphylactic Reaction to Neomycin" OR: "Diagnosis, Active: Varicella Zoster" OR: "Diagnosis, Inactive: Varicella Zoster" OR: "Diagnosis, Resolved: Varicella Zoster" OR: "Laboratory Test, Result: Varicella Zoster Antigen Test (result: 'Seropositive')" <= 730 day(s) starts after start of "Patient Characteristic Birthdate: birth date"

7. AND: a. OR: "Diagnosis, Active: Anaphylactic Reaction to Pneumococcal Conjugate Vaccine" <= 730

day(s) starts after start of "Patient Characteristic Birthdate: birth date" b. OR:

AND: "Occurrence D of Medication, Administered: Pneumococcal Conjugate Vaccine" >= 1 day(s) starts after end of ("Occurrence C of Medication, Administered: Pneumococcal Conjugate Vaccine" >= 1 day(s) starts after end of ("Occurrence B of Medication, Administered: Pneumococcal Conjugate Vaccine" >= 1 day(s) starts after end of "Occurrence A of Medication, Administered: Pneumococcal Conjugate Vaccine")) AND: "Occurrence A of Medication, Administered: Pneumococcal Conjugate Vaccine" >= 42 day(s) ends after start of "Patient Characteristic Birthdate: birth date" AND:

AND: "Occurrence A of Medication, Administered: Pneumococcal Conjugate Vaccine" AND: "Occurrence B of Medication, Administered: Pneumococcal Conjugate Vaccine" AND: "Occurrence C of Medication, Administered: Pneumococcal Conjugate Vaccine" AND: "Occurrence D of Medication, Administered: Pneumococcal Conjugate Vaccine" <= 730 day(s) ends after start of "Patient Characteristic Birthdate: birth date"

c. OR: AND: "Occurrence D of Procedure, Performed: Pneumococcal Conjugate Vaccine Administered" >= 1 day(s) starts after end of ("Occurrence C of Procedure, Performed: Pneumococcal Conjugate Vaccine Administered" >= 1 day(s) starts after end of ("Occurrence B of Procedure, Performed: Pneumococcal Conjugate Vaccine Administered" >= 1 day(s) starts after end of "Occurrence A of Procedure, Performed: Pneumococcal Conjugate Vaccine Administered")) AND: "Occurrence A of Procedure, Performed: Pneumococcal Conjugate Vaccine Administered" >= 42 day(s) ends after start of "Patient Characteristic Birthdate: birth date" AND:

AND: "Occurrence A of Procedure, Performed: Pneumococcal Conjugate Vaccine Administered" AND: "Occurrence B of Procedure, Performed: Pneumococcal Conjugate Vaccine Administered" AND: "Occurrence C of Procedure, Performed: Pneumococcal Conjugate Vaccine Administered"

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AND: "Occurrence D of Procedure, Performed: Pneumococcal Conjugate Vaccine Administered" <= 730 day(s) ends after start of "Patient Characteristic Birthdate: birth date"

8. AND: a. OR:

OR: "Occurrence A of Medication, Administered: Hepatitis A Vaccine" OR: "Occurrence A of Procedure, Performed: Hepatitis A Vaccine Administered" <= 730 day(s) ends after start of "Patient Characteristic Birthdate: birth date"

b. OR: OR: "Diagnosis, Active: Anaphylactic Reaction to Hepatitis A Vaccine" OR: "Diagnosis, Active: Hepatitis A" OR: "Diagnosis, Resolved: Hepatitis A" OR: "Laboratory Test, Result: Hepatitis A Antigen Test (result: 'Seropositive')" <= 730 day(s) starts after start of "Patient Characteristic Birthdate: birth date"

9. AND: a. OR: "Diagnosis, Active: Anaphylactic Reaction to Rotavirus Vaccine" <= 730 day(s) starts after

start of "Patient Characteristic Birthdate: birth date" b. OR:

AND: "Occurrence B of Medication, Administered: Rotavirus Vaccine (2 dose schedule)" >= 1 day(s) starts after end of "Occurrence A of Medication, Administered: Rotavirus Vaccine (2 dose schedule)" AND: "Occurrence A of Medication, Administered: Rotavirus Vaccine (2 dose schedule)" >= 42 day(s) ends after start of "Patient Characteristic Birthdate: birth date" AND:

AND: "Occurrence A of Medication, Administered: Rotavirus Vaccine (2 dose schedule)" AND: "Occurrence B of Medication, Administered: Rotavirus Vaccine (2 dose schedule)" <= 730 day(s) ends after start of "Patient Characteristic Birthdate: birth date"

c. OR: AND: "Occurrence B of Procedure, Performed: Rotavirus Vaccine (2 dose schedule) Administered" >= 1 day(s) starts after end of "Occurrence A of Procedure, Performed: Rotavirus Vaccine (2 dose schedule) Administered" AND: "Occurrence A of Procedure, Performed: Rotavirus Vaccine (2 dose schedule) Administered" >= 42 day(s) ends after start of "Patient Characteristic Birthdate: birth date" AND:

AND: "Occurrence A of Procedure, Performed: Rotavirus Vaccine (2 dose schedule) Administered" AND: "Occurrence B of Procedure, Performed: Rotavirus Vaccine (2 dose schedule) Administered"

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<= 730 day(s) ends after start of "Patient Characteristic Birthdate: birth date" d. OR:

AND: AND: "Occurrence A of Medication, Administered: Rotavirus Vaccine (3 dose schedule)" AND: "Occurrence B of Medication, Administered: Rotavirus Vaccine (3 dose schedule)" AND: "Occurrence A of Medication, Administered: Rotavirus Vaccine (2 dose schedule)" >= 42 day(s) ends after start of "Patient Characteristic Birthdate: birth date"

AND: AND: "Occurrence A of Medication, Administered: Rotavirus Vaccine (3 dose schedule)" AND: "Occurrence B of Medication, Administered: Rotavirus Vaccine (3 dose schedule)" AND: "Occurrence A of Medication, Administered: Rotavirus Vaccine (2 dose schedule)" <= 730 day(s) ends after start of "Patient Characteristic Birthdate: birth date"

AND: OR: "Occurrence A of Medication, Administered: Rotavirus Vaccine (2 dose schedule)" >= 1 day(s) starts after end of ("Occurrence B of Medication, Administered: Rotavirus Vaccine (3 dose schedule)" >= 1 day(s) starts after end of "Occurrence A of Medication, Administered: Rotavirus Vaccine (3 dose schedule)") OR: "Occurrence B of Medication, Administered: Rotavirus Vaccine (3 dose schedule)" >= 1 day(s) starts after end of ("Occurrence A of Medication, Administered: Rotavirus Vaccine (2 dose schedule)" >= 1 day(s) starts after end of "Occurrence A of Medication, Administered: Rotavirus Vaccine (3 dose schedule)") OR: "Occurrence B of Medication, Administered: Rotavirus Vaccine (3 dose schedule)" >= 1 day(s) starts after end of ("Occurrence A of Medication, Administered: Rotavirus Vaccine (3 dose schedule)" >= 1 day(s) starts after end of "Occurrence A of Medication, Administered: Rotavirus Vaccine (2 dose schedule)")

e. OR: AND:

AND: "Occurrence A of Procedure, Performed: Rotavirus Vaccine (3 dose schedule) Administered" AND: "Occurrence B of Procedure, Performed: Rotavirus Vaccine (3 dose schedule) Administered"

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AND: "Occurrence A of Procedure, Performed: Rotavirus Vaccine (2 dose schedule) Administered" >= 42 day(s) ends after start of "Patient Characteristic Birthdate: birth date"

AND: AND: "Occurrence A of Procedure, Performed: Rotavirus Vaccine (3 dose schedule) Administered" AND: "Occurrence B of Procedure, Performed: Rotavirus Vaccine (3 dose schedule) Administered" AND: "Occurrence A of Procedure, Performed: Rotavirus Vaccine (2 dose schedule) Administered" <= 730 day(s) ends after start of "Patient Characteristic Birthdate: birth date"

AND: OR: "Occurrence A of Procedure, Performed: Rotavirus Vaccine (2 dose schedule) Administered" >= 1 day(s) starts after end of ("Occurrence B of Procedure, Performed: Rotavirus Vaccine (3 dose schedule) Administered" >= 1 day(s) starts after end of "Occurrence A of Procedure, Performed: Rotavirus Vaccine (3 dose schedule) Administered") OR: "Occurrence B of Procedure, Performed: Rotavirus Vaccine (3 dose schedule) Administered" >= 1 day(s) starts after end of ("Occurrence A of Procedure, Performed: Rotavirus Vaccine (2 dose schedule) Administered" >= 1 day(s) starts after end of "Occurrence A of Procedure, Performed: Rotavirus Vaccine (3 dose schedule) Administered") OR: "Occurrence B of Procedure, Performed: Rotavirus Vaccine (3 dose schedule) Administered" >= 1 day(s) starts after end of ("Occurrence A of Procedure, Performed: Rotavirus Vaccine (3 dose schedule) Administered" >= 1 day(s) starts after end of "Occurrence A of Procedure, Performed: Rotavirus Vaccine (2 dose schedule) Administered")

f. OR: AND: "Occurrence C of Medication, Administered: Rotavirus Vaccine (3 dose schedule)" >= 1 day(s) starts after end of ("Occurrence B of Medication, Administered: Rotavirus Vaccine (3 dose schedule)" >= 1 day(s) starts after end of "Occurrence A of Medication, Administered: Rotavirus Vaccine (3 dose schedule)") AND: "Occurrence A of Medication, Administered: Rotavirus Vaccine (3 dose schedule)" >= 42 day(s) ends after start of "Patient Characteristic Birthdate: birth date" AND:

AND: "Occurrence A of Medication, Administered: Rotavirus Vaccine (3 dose schedule)" AND: "Occurrence B of Medication, Administered: Rotavirus Vaccine (3 dose schedule)" AND: "Occurrence C of Medication, Administered: Rotavirus Vaccine (3 dose schedule)"

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<= 730 day(s) ends after start of "Patient Characteristic Birthdate: birth date" g. OR:

AND: "Occurrence C of Procedure, Performed: Rotavirus Vaccine (3 dose schedule) Administered" >= 1 day(s) starts after end of ("Occurrence B of Procedure, Performed: Rotavirus Vaccine (3 dose schedule) Administered" >= 1 day(s) starts after end of "Occurrence A of Procedure, Performed: Rotavirus Vaccine (3 dose schedule) Administered") AND: "Occurrence A of Procedure, Performed: Rotavirus Vaccine (3 dose schedule) Administered" >= 42 day(s) ends after start of "Patient Characteristic Birthdate: birth date" AND:

AND: "Occurrence A of Procedure, Performed: Rotavirus Vaccine (3 dose schedule) Administered" AND: "Occurrence B of Procedure, Performed: Rotavirus Vaccine (3 dose schedule) Administered" AND: "Occurrence C of Procedure, Performed: Rotavirus Vaccine (3 dose schedule) Administered" <= 730 day(s) ends after start of "Patient Characteristic Birthdate: birth date"

10. AND: a. OR:

AND: "Occurrence B of Medication, Administered: Influenza Vaccine" >= 1 day(s) starts after end of "Occurrence A of Medication, Administered: Influenza Vaccine" AND: "Occurrence A of Medication, Administered: Influenza Vaccine" >= 180 day(s) ends after start of "Patient Characteristic Birthdate: birth date" AND:

AND: "Occurrence A of Medication, Administered: Influenza Vaccine" AND: "Occurrence B of Medication, Administered: Influenza Vaccine" <= 730 day(s) ends after start of "Patient Characteristic Birthdate: birth date"

b. OR: AND: "Occurrence B of Procedure, Performed: Influenza Vaccine Administered" >= 1 day(s) starts after end of "Occurrence A of Procedure, Performed: Influenza Vaccine Administered" AND: "Occurrence A of Procedure, Performed: Influenza Vaccine Administered" >= 180 day(s) ends after start of "Patient Characteristic Birthdate: birth date" AND:

AND: "Occurrence A of Procedure, Performed: Influenza Vaccine Administered" AND: "Occurrence B of Procedure, Performed: Influenza Vaccine Administered" <= 730 day(s) ends after start of "Patient Characteristic Birthdate: birth date"

c. OR: OR: "Diagnosis, Active: Anaphylactic Reaction to Influenza Vaccine" OR: "Diagnosis, Active: Malignant Neoplasm of Lymphatic and Hematopietic Tissue" OR: "Diagnosis, Active: Anaphylactic Reaction to Neomycin"

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<= 730 day(s) starts after start of "Patient Characteristic Birthdate: birth date"

3.4.2 Calculations

Initial Patient Population: Number of unique female patients of age = 2 years before the measurement period with the given Issuer(s) of Patient ID and for the given Facilities who has a study with a procedure with a code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'ENCOUNTER' AND CODESYSTEM = 'CPT' and SETNAME IN ('OFFICE VISIT', 'HOME HEALTHCARE SERVICES', 'PREVENTIVE CARE- INITIAL OFFICE VISIT, 0 TO 17', 'PREVENTIVE CARE - ESTABLISHED OFFICE VISIT, 0 TO 17') or with a problem with a code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'ENCOUNTER' AND CODESYSTEM = ' SNOMEDCT' and SETNAME = 'FACE-TO-FACE INTERACTION' with in the reporting period Denominator: Same as Initial Patient Population. Numerator: Number of patients in the denominator who has 4 or more number of vaccine of code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'MEDICATION' AND CODESYSTEM = 'CVX' and SETNAME = 'DTAP VACCINE' with the immunization dates are different and is between 42 days and 730 days of the date of birth Or 4 or more number of studies with procedure of code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'PROCEDURE' and CODESYSTEM = 'CPT' and SETNAME = 'DTAP VACCINE ADMINISTERED' with the study date between 42 days and 730 days of the date of birth Or who has a study with diagnosis with code that matches in the MUVALUESET for the given CMSID with SETTYPE = ' CONDITION-DIAGNOSIS-PROBLEM’ AND CODESYSTEM IN ('ICD10CM','ICD9CM') and SETNAME IN ('ANAPHYLACTIC REACTION TO DTAP VACCINE','ENCEPHALOPATHY') with the study dates are different and less than 730 days from the date of birth. Or who has a problem with code that matches in the MUVALUESET for the given CMSID with SETTYPE = ' CONDITION-DIAGNOSIS-PROBLEM’ AND CODESYSTEM = 'SNOMEDCT' and SETNAME IN ('ANAPHYLACTIC REACTION TO DTAP VACCINE','ENCEPHALOPATHY'). And who has 4 or more number of vaccine of code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'MEDICATION' AND CODESYSTEM = 'CVX' and SETNAME = 'INACTIVATED POLIO VACCINE (IPV)' with the immunization dates are different and are between 42 days and 730 days of the date of birth Or 4 or more number of studies with procedure of code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'PROCEDURE' and CODESYSTEM = 'CPT' and SETNAME = 'DTAP VACCINE ADMINISTERED' with the study dates are different and are between 42 days and 730 days of the date of birth Or who has a study with diagnosis with code that matches in the MUVALUESET for the given CMSID with SETTYPE = ' CONDITION-DIAGNOSIS-PROBLEM’ AND CODESYSTEM IN ('ICD10CM','ICD9CM') and SETNAME IN ('ANAPHYLACTIC REACTION TO INACTIVATED POLIO VACCINE (IPV)','ANAPHYLACTIC REACTION TO STREPTOMYCIN','ANAPHYLACTIC REACTION TO POLYMYXIN', 'ANAPHYLACTIC REACTION TO NEOMYCIN') with the study date less than 730 days from the date of birth. Or who has a problem with code that matches in the MUVALUESET for the given CMSID with

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SETTYPE = ' CONDITION-DIAGNOSIS-PROBLEM’ AND CODESYSTEM = 'SNOMEDCT' and SETNAME IN ('ANAPHYLACTIC REACTION TO INACTIVATED POLIO VACCINE (IPV)','ANAPHYLACTIC REACTION TO STREPTOMYCIN', 'ANAPHYLACTIC REACTION TO POLYMYXIN', 'ANAPHYLACTIC REACTION TO NEOMYCIN') And who has a vaccine of code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'MEDICATION' AND CODESYSTEM = 'CVX' and SETNAME = ' MEASLES, MUMPS AND RUBELLA (MMR) VACCINE' with the immunization date less than 730 days of the date of birth Or a study with procedure of code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'PROCEDURE' and CODESYSTEM = 'CPT' and SETNAME = 'MEASLES, MUMPS AND RUBELLA (MMR) VACCINE ADMINISTERED' with the study date less than 730 days of the date of birth Or who has a study with diagnosis with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM’ AND CODESYSTEM IN ('ICD10CM','ICD9CM') and SETNAME IN ('DISORDERS OF THE IMMUNE SYSTEM','HIV', 'MALIGNANT NEOPLASM OF LYMPHATIC TISSUE', 'ANAPHYLACTIC REACTION TO NEOMYCIN') with the study date less than 730 days from the date of birth. Or who has a problem with code that matches in the MUVALUESET for the given CMSID with SETTYPE = ' CONDITION-DIAGNOSIS-PROBLEM’ AND CODESYSTEM = 'SNOMEDCT' and SETNAME IN ('DISORDERS OF THE IMMUNE SYSTEM','HIV', 'MALIGNANT NEOPLASM OF LYMPHATIC TISSUE', 'ANAPHYLACTIC REACTION TO NEOMYCIN') with problem date is less than 730 days of the date of birth Or with a study with diagnosis with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM’ AND CODESYSTEM IN ('ICD10CM','ICD9CM') and SETNAME IN ('MEASLES') with the study date less than 730 days of the date of birth Or with a lab result with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'LABORATORY TEST’ AND CODESYSTEM = 'LOINC' and SETNAME IN ('MEASLES ANTIGEN TEST') with the order date less than 730 days of the date of birth and the result name = 'SEROPOSITIVE'. And with diagnosis with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM’ AND CODESYSTEM IN ('ICD10CM','ICD9CM') and SETNAME IN ('MUMPS') with the study date less than 730 days from the date of birth Or with a lab result with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'LABORATORY TEST’ AND CODESYSTEM = 'LOINC' and SETNAME IN ('MUMPS ANTIGEN TEST') with the order date less than 730 days of the date of birth and the result name = 'SEROPOSITIVE' And with diagnosis with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM’ AND CODESYSTEM IN ('ICD10CM','ICD9CM') and SETNAME IN ('RUBELLA') with the study date less than 730 days from the date of birth Or with a lab result with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'LABORATORY TEST’ AND CODESYSTEM = 'LOINC' and SETNAME IN ('MUMPS ANTIGEN TEST') with the order date less than 730 days of the date of birth and the result name = ' RUBELLA ANTIGEN TEST' And who has 3 or more number of vaccine of code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'MEDICATION' AND CODESYSTEM = 'CVX' and SETNAME = ' HEMOPHILUS INFLUENZE B (HIB) VACCINE' with the immunization dates are different and are between 42 days and 730 days of the date of birth Or 3 or more number of studies with procedure of code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'PROCEDURE' and CODESYSTEM = 'CPT' and SETNAME = ' HEMOPHILUS INFLUENZE B (HIB)

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VACCINE ADMINISTERED' with the study dates are different and are between 42 days and 730 days of the date of birth Or who has a study with diagnosis with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM’ AND CODESYSTEM IN ('ICD10CM','ICD9CM') and SETNAME IN (' ANAPHYLACTIC REACTION TO HEMOPHILUS INFLUENZA B (HIB) VACCINE') with the study date less than 730 days from the date of birth. Or who has a problem with code that matches in the MUVALUESET for the given CMSID with SETTYPE = ' CONDITION-DIAGNOSIS-PROBLEM’ AND CODESYSTEM = 'SNOMEDCT' and SETNAME IN ('ANAPHYLACTIC REACTION TO HEMOPHILUS INFLUENZA B (HIB) VACCINE') And who has 3 or more number of vaccine of code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'MEDICATION' AND CODESYSTEM = 'CVX' and SETNAME = 'HEPATITIS B VACCINE' with the immunization dates are different and are between 42 days and 730 days of the date of birth Or 3 or more number of studies with procedure of code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'PROCEDURE' and CODESYSTEM = 'CPT' and SETNAME = 'HEPATITIS B VACCINE ADMINISTERED' with the study dates are different and are between 42 days and 730 days of the date of birth Or who has a study with diagnosis with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM’ AND CODESYSTEM IN ('ICD10CM','ICD9CM') and SETNAME IN ('ANAPHYLACTIC REACTION TO HEPATITIS B VACCINE', 'ANAPHYLACTIC REACTION TO COMMON BAKER''S YEAST', 'HEPATITIS B') with the study date less than 730 days from the date of birth. Or with a problem with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM’ AND CODESYSTEM = 'SNOMEDCT' and SETNAME IN ('ANAPHYLACTIC REACTION TO HEPATITIS B VACCINE', 'ANAPHYLACTIC REACTION TO COMMON BAKER''S YEAST', 'HEPATITIS B') Or with a lab result with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'LABORATORY TEST’ AND CODESYSTEM = 'LOINC' and SETNAME IN ('HEPATITIS B ANTIGEN TEST') with the order date less than 730 days of the date of birth and the result name = 'SEROPOSITIVE' And who has a vaccine of code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'MEDICATION' AND CODESYSTEM = 'CVX' and SETNAME = 'VARICELLA ZOSTER VACCINE (VZV)' with the immunization dates are different and are between 42 days and 730 days of the date of birth Or a study with procedure of code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'PROCEDURE' and CODESYSTEM = 'CPT' and SETNAME = 'VARICELLA ZOSTER VACCINE (VZV) ADMINISTERED' with the study dates are different and are between 42 days and 730 days of the date of birth Or who has a study with diagnosis with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM’ AND CODESYSTEM IN ('ICD10CM','ICD9CM') and SETNAME IN ('DISORDERS OF THE IMMUNE SYSTEM','HIV', 'MALIGNANT NEOPLASM OF LYMPHATIC TISSUE', 'ANAPHYLACTIC REACTION TO NEOMYCIN') with the study date less than 730 days from the date of birth. Or who has a problem with code that matches in the MUVALUESET for the given CMSID with SETTYPE = ' CONDITION-DIAGNOSIS-PROBLEM’ AND CODESYSTEM = 'SNOMEDCT' and SETNAME IN ('DISORDERS OF THE IMMUNE SYSTEM', 'HIV', 'MALIGNANT NEOPLASM OF LYMPHATIC TISSUE', 'ANAPHYLACTIC REACTION TO NEOMYCIN', 'VARICELLA ZOSTER') with problem date is less than 730 days of the date of birth Or with a study with problem with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM’ AND CODESYSTEM = 'SNOMEDCT' and SETNAME IN ('DISORDERS OF THE IMMUNE SYSTEM', 'HIV', 'MALIGNANT NEOPLASM OF LYMPHATIC TISSUE', 'ANAPHYLACTIC REACTION TO NEOMYCIN', 'VARICELLA ZOSTER') with the study date less than 730 days of the date of birth Or with a lab result with code that matches in the

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MUVALUESET for the given CMSID with SETTYPE = 'LABORATORY TEST’ AND CODESYSTEM = 'LOINC' and SETNAME IN ('VARICELLA ZOSTER ANTIGEN TEST') with the order date less than 730 days of the date of birth and the result name = 'SEROPOSITIVE'. And who has 3 or more number of vaccine of code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'MEDICATION' AND CODESYSTEM = 'CVX' and SETNAME = 'PNEUMOCOCCAL CONJUGATE VACCINE' with the immunization dates are different and are between 42 days and 730 days of the date of birth Or 3 or more number of studies with procedure of code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'PROCEDURE' and CODESYSTEM = 'CPT' and SETNAME = 'PNEUMOCOCCAL CONJUGATE VACCINE ADMINISTERED' with the study dates are different and are between 42 days and 730 days of the date of birth Or who has a study with diagnosis with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM’ AND CODESYSTEM IN ('ICD10CM','ICD9CM') and SETNAME IN ('ANAPHYLACTIC REACTION TO PNEUMOCOCCAL CONJUGATE VACCINE') with the study date less than 730 days from the date of birth. Or with a problem with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM’ AND CODESYSTEM = 'SNOMEDCT' and SETNAME IN ('ANAPHYLACTIC REACTION TO PNEUMOCOCCAL CONJUGATE VACCINE') And who has a vaccine of code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'MEDICATION' AND CODESYSTEM = 'CVX' and SETNAME = 'HEPATITIS A VACCINE' with the immunization dates are different and are between 42 days and 730 days of the date of birth Or a study with procedure of code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'PROCEDURE' and CODESYSTEM = 'CPT' and SETNAME = 'HEPATITIS A VACCINE ADMINISTERED' with the study dates are different and are between 42 days and 730 days of the date of birth Or who has a study with diagnosis with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM’ AND CODESYSTEM IN ('ICD10CM','ICD9CM') and SETNAME IN ('ANAPHYLACTIC REACTION TO HEPATITIS A VACCINE', 'HEPATITIS A') with the study date less than 730 days from the date of birth. Or who has a problem with code that matches in the MUVALUESET for the given CMSID with SETTYPE = ' CONDITION-DIAGNOSIS-PROBLEM’ AND CODESYSTEM = 'SNOMEDCT' and SETNAME IN ('ANAPHYLACTIC REACTION TO HEPATITIS A VACCINE', 'HEPATITIS A') with problem date is less than 730 days of the date of birth Or with a lab result with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'LABORATORY TEST’ AND CODESYSTEM = 'LOINC' and SETNAME IN ('HEPATITIS A ANTIGEN TEST') with the order date less than 730 days of the date of birth and the result name = 'SEROPOSITIVE'. And who has 2 or more number of vaccine of code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'MEDICATION' AND CODESYSTEM = 'CVX' and SETNAME = 'ROTAVIRUS VACCINE (2 DOSE SCHEDULE)' with the immunization dates are different and are between 42 days and 730 days of the date of birth Or 2 or more number of studies with procedure of code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'PROCEDURE' and CODESYSTEM = 'CPT' and SETNAME = 'ROTAVIRUS VACCINE (2 DOSE SCHEDULE) ADMINISTERED' with the study dates are different and are between 42 days and 730 days of the date of birth Or 3 or more number of vaccine of code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'MEDICATION' AND CODESYSTEM = 'CVX' and SETNAME = 'ROTAVIRUS VACCINE (3 DOSE SCHEDULE)' with the immunization dates are different and are between 42 days and 730 days of the date of birth Or 3 or more number of studies with procedure of code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'PROCEDURE' and CODESYSTEM = 'CPT' and SETNAME = 'ROTAVIRUS VACCINE (3 DOSE SCHEDULE)

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ADMINISTERED' with the study dates are different and are between 42 days and 730 days of the date of birth Or 3 or more number of vaccine of code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'MEDICATION' AND CODESYSTEM = 'CVX' and SETNAME = ''ROTAVIRUS VACCINE (2 DOSE SCHEDULE)', 'ROTAVIRUS VACCINE (3 DOSE SCHEDULE)'' with the immunization dates are different and are between 42 days and 730 days of the date of birth Or 3 or more number of studies with procedure of code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'PROCEDURE' and CODESYSTEM = 'CPT' and SETNAME in ('ROTAVIRUS VACCINE (2 DOSE SCHEDULE) ADMINISTERED', 'ROTAVIRUS VACCINE (3 DOSE SCHEDULE) ADMINISTERED') with the study dates are different and are between 42 days and 730 days of the date of birth Or with a study with diagnosis with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM’ AND CODESYSTEM IN ('ICD10CM','ICD9CM') and SETNAME IN ('ANAPHYLACTIC REACTION TO ROTAVIRUS VACCINE') with the study date less than 730 days from the date of birth. Or with a problem with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM’ AND CODESYSTEM = 'SNOMEDCT' and SETNAME IN ('ANAPHYLACTIC REACTION TO ROTAVIRUS VACCINE') And who has 2 or more number of vaccine of code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'MEDICATION' AND CODESYSTEM = 'CVX' and SETNAME = 'INFLUENZA VACCINE' with the immunization dates are different and are between 180 days and 730 days of the date of birth Or 2 or more number of studies with procedure of code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'PROCEDURE' and CODESYSTEM = 'CPT' and SETNAME = 'INFLUENZA VACCINE ADMINISTERED' with the study dates are different and are between 180 days and 730 days of the date of birth Or who has a study with diagnosis with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM’ AND CODESYSTEM IN ('ICD10CM','ICD9CM') and SETNAME IN ('ANAPHYLACTIC REACTION TO INFLUENZA VACCINE', 'MALIGNANT NEOPLASM OF LYMPHATIC TISSUE', 'ANAPHYLACTIC REACTION TO NEOMYCIN') with the study date less than 730 days from the date of birth. Or with a problem with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM’ AND CODESYSTEM = 'SNOMEDCT' and SETNAME IN ('ANAPHYLACTIC REACTION TO INFLUENZA VACCINE', 'MALIGNANT NEOPLASM OF LYMPHATIC TISSUE', 'ANAPHYLACTIC REACTION TO NEOMYCIN') 3.5 Breast Cancer Screening Measure Identifier: 125 Version: 3 Description: Percentage of women 40–69 years of age who had a mammogram to screen for breast cancer. 3.5.1 Definition: Initial Patient Population:

o AND: "Patient Characteristic Birthdate: birth date" >= 41 year(s) starts before start of "Measurement Period"

o AND: "Patient Characteristic Birthdate: birth date" < 69 year(s) starts before start of "Measurement Period"

o AND: "Patient Characteristic Sex: Female" o AND:

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OR: "Encounter, Performed: Office Visit"

OR: "Encounter, Performed: Face-to-Face Interaction"

OR: "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up"

OR: "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up"

OR: "Encounter, Performed: Home Healthcare Services"

OR: "Encounter, Performed: Annual Wellness Visit"

during "Measurement Period"

Denominator:

o AND: "Initial Patient Population"

Denominator Exclusions:

o AND:

OR: "Procedure, Performed: Bilateral Mastectomy"

OR: Count = 2 of:"Procedure, Performed: Unilateral Mastectomy"

ends before or during "Measurement Period"

Numerator:

o AND: "Diagnostic Study, Result: Mammogram (result)" <= 12 month(s) ends before or during "Measurement Period"

3.5.2 Calculations

Initial Patient Population: Number of unique female patients of age >= 41 and age < 69 years before the measurement period with the given Issuer(s) of Patient ID and for the given Facilities who has a study with a procedure with a code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'ENCOUNTER' AND CODESYSTEM = 'CPT' and SETNAME IN ('OFFICE VISIT', 'HOME HEALTHCARE SERVICES', 'PREVENTIVE CARE SERVICES-INITIAL OFFICE VISIT, 18 AND UP', 'PREVENTIVE CARE SERVICES - ESTABLISHED OFFICE VISIT, 18 AND UP') or with a problem with a code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'ENCOUNTER' AND CODESYSTEM = ' SNOMEDCT' and SETNAME = 'FACE-TO-FACE INTERACTION' with in the reporting period Denominator: Same as Initial Patient Population. Denominator Exclusions: Patients with a problem of code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'PROCEDURE' AND CODESYSTEM = 'SNOMEDCT' AND SETNAME = 'BILATERAL MASTECTOMY' or with two problems of code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'PROCEDURE' AND CODESYSTEM = 'SNOMEDCT' AND SETNAME = 'UNILATERAL MASTECTOMY' with problem date less than the end of the reporting period Or study with procedure of code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'PROCEDURE' AND CODESYSTEM = 'CPT' AND SETNAME = ' UNILATERAL MASTECTOMY'

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Numerator: Number of patients in the denominator who have lab result with code that matches in the MUVALUESET for the given CMSID with SETTYPE = ' DIAGNOSTIC STUDY' AND CODESYSTEM = ' LOINC' AND SETNAME = 'MAMMOGRAM' and the order date is between 12 months prior to the start date of the reporting period and the end date of the reporting period. 3.6 Pneumonia Vaccination Status for Older Adults

Measure Identifier: 127 Version: 3

Description: Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine. 3.6.1 Definition: Initial Patient Population:

o AND: "Patient Characteristic Birthdate: birth date" >= 65 year(s) starts before start of "Measurement

Period" o AND:








Denominator:


Numerator:

o AND:

OR: "Medication, Administered: Pneumococcal Vaccine"

OR: "Procedure, Performed: Pneumococcal Vaccine Administered"

OR: "Risk Category Assessment: History of Pneumococcal Vaccine"

starts before or during "Measurement Period"

3.6.2 Calculations

Initial Patient Population: Number of unique patients of age >= 65 years before the measurement period with the given Issuer(s) of Patient ID and for the given Facilities who has a study with a procedure with a code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'ENCOUNTER' AND CODESYSTEM = 'CPT' and SETNAME IN ('OFFICE VISIT', 'HOME HEALTHCARE SERVICES', 'PREVENTIVE CARE SERVICES-INITIAL OFFICE VISIT, 18 AND UP', 'PREVENTIVE CARE SERVICES - ESTABLISHED OFFICE VISIT, 18 AND UP') and with the study

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date within the reporting period Or who has a problem with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'ENCOUNTER' AND CODESYSTEM = 'SNOMEDCT' and SETNAME = 'FACE-TO-FACE INTERACTION' and the problem date within the reporting period. Denominator: Same as Initial Patient Population. Numerator: Number of patients in the denominator who has a vaccine with CVX code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'MEDICATION' AND CODESYSTEM = 'CVX' and SETNAME = 'PNEUMOCOCCAL VACCINE' and Immunization date is less than the end date of the reporting period or who has a problem with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'RISK CATEGORY-ASSESSMENT' AND CODESYSTEM = 'SNOMEDCT' and SETNAME = 'HISTORY OF PNEUMOCOCCAL VACCINE' and problem date is less than the end date of the reporting period. 3.7 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention


Description: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user. 3.7.1 Definition: Initial Patient Population:

o AND: "Patient Characteristic Birthdate: birth date" >= 18 year(s) starts before start of "Measurement Period"

o AND:

OR: Count >= 2 of:

OR: "Encounter, Performed: Psych Visit - Diagnostic Evaluation"

OR: "Encounter, Performed: Health and Behavioral Assessment - Initial"

OR: "Encounter, Performed: Health & Behavioral Assessment - Individual"

OR: "Encounter, Performed: Occupational Therapy Evaluation"


OR: "Encounter, Performed: Psych Visit - Psychotherapy"

OR: "Encounter, Performed: Psychoanalysis"

OR: "Encounter, Performed: Ophthalmological Services"

OR: Count >= 1 of:

OR: "Encounter, Performed: Preventive Care Services - Group Counseling"

OR: "Encounter, Performed: Preventive Care Services - Other"



OR: "Encounter, Performed: Preventive Care Services-Individual Counseling"




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Denominator:


Numerator:

o AND:

OR:

AND: "Risk Category Assessment: Tobacco Use Screening"

AND: "Occurrence A of Patient Characteristic: Tobacco Non-User"

AND NOT: "Patient Characteristic: Tobacco User" starts after end of "Occurrence A of Patient Characteristic: Tobacco Non-User"

OR:

AND:

AND: "Risk Category Assessment: Tobacco Use Screening"

AND: "Occurrence A of Patient Characteristic: Tobacco User"

AND NOT: "Patient Characteristic: Tobacco Non-User" starts after end of "Occurrence A of Patient Characteristic: Tobacco User"

AND:

OR: "Intervention, Performed: Tobacco Use Cessation Counseling"

OR: "Medication, Active: Tobacco Use Cessation Pharmacotherapy"

OR: "Medication, Order: Tobacco Use Cessation Pharmacotherapy"

<= 24 month(s) starts before or during "Measurement End Date"

Denominator Exceptions:

o AND:

OR: "Risk Category Assessment not done: Medical Reason" for "Tobacco Use Screening" <= 24

month(s) starts before or during "Measurement End Date"

OR:

AND: "Occurrence A of Diagnosis, Active: Limited Life Expectancy" starts before or during "Measurement End Date"

AND NOT: "Occurrence A of Diagnosis, Active: Limited Life Expectancy" ends before or during "Measurement End Date"

3.7.2 Calculations

Initial Patient Population: Number of unique patients of age >= 18 years before the measurement period with the given Issuer(s) of Patient ID and for the given Facilities who has two or more studies with a procedure with a code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'ENCOUNTER' AND CODESYSTEM = 'CPT' and SETNAME IN ('PSYCH VISIT - DIAGNOSTIC EVALUATION', 'HEALTH AND BEHAVIORAL ASSESSMENT - INITIAL', 'HEALTH & BEHAVIORAL ASSESSMENT - INDIVIDUAL', 'OCCUPATIONAL THERAPY EVALUATION', 'OFFICE VISIT', 'PSYCH VISIT - PSYCHOTHERAPY', 'PSYCHOANALYSIS', 'OPHTHALMOLOGICAL SERVICES') Or at least one study with a procedure with a code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'ENCOUNTER' AND CODESYSTEM = 'CPT' and SETNAME IN ('PREVENTIVE CARE SERVICES - GROUP COUNSELING', 'PREVENTIVE CARE SERVICES - OTHER', 'PREVENTIVE CARE SERVICES-INITIAL OFFICE VISIT, 18 AND UP', 'PREVENTIVE CARE SERVICES - ESTABLISHED OFFICE VISIT, 18 AND UP', 'PREVENTIVE CARE SERVICES-INDIVIDUAL COUNSELING') with study date within the reporting period Or at least one

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problem with a code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'ENCOUNTER' AND CODESYSTEM = 'SNOMEDCT' and SETNAME = 'FACE-TO-FACE INTERACTION' Denominator: Same as Initial Patient Population. Numerator: Number of patients in the denominator who has a lab result with a code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'RISK CATEGORY-ASSESSMENT' AND CODESYSTEM = 'LOINC' and SETNAME IN ('TOBACCO USE SCREENING’) and who has problem with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'INDIVIDUAL CHARACTERISTIC' AND CODESYSTEM = ' SNOMEDCT' and SETNAME IN ('TOBACCO USE SCREENING’) and do not have a problem with the code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'INDIVIDUAL CHARACTERISTIC' AND CODESYSTEM = ' SNOMEDCT' and SETNAME IN ('TOBACCO USER’) and problem date greater than the previous Or who has problems with the code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'INDIVIDUAL CHARACTERISTIC' AND CODESYSTEM = ' SNOMEDCT' and SETNAME IN ('TOBACCO USER’) and do not have problems with the code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'INDIVIDUAL CHARACTERISTIC' AND CODESYSTEM = ' SNOMEDCT' and SETNAME = 'TOBACCO NON-USER’ and problem date greater than the previous and with problem dates between 24 months prior to the end date of the reporting period and the end of the reporting period and who has a procedure with the code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'INTERVENTION' AND CODESYSTEM = 'CPT' and SETNAME IN (‘TOBACCO USE CESSATION COUNSELING’) Or has a medication with the code that matches the in the MUVALUESET for the given CMSID with SETTYPE = 'MEDICATION' AND CODESYSTEM = 'RXNORM' and SETNAME IN (‘TOBACCO USE CESSATION PHARMACOTHERAPY’) and with the prescription date is between 24 months prior to the end of the reporting period and the end date of the reporting period Denominator Exceptions: Patients with problem of code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM' AND CODESYSTEM = 'SNOMEDCT' AND SETNAME = 'LIMITED LIFE EXPECTANCY' with the problem date is less than the end of the reporting period Or with a lab result with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'RISK CATEGORY-ASSESSMENT’ AND CODESYSTEM = 'LOINC' and SETNAME IN ('TOBACCO USE SCREENING') with the order date is between the 24 days prior to the end of the reporting period and the end of the reporting period and with problems with the code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'ATTRIBUTE' AND CODESYSTEM = 'SNOMEDCT' and SETNAME IN ('MEDICAL REASON’) with the problem date is between the 24 days prior to the end of the reporting period and the end of the reporting period. 3.8 Preventive Care and Screening: Influenza Immunization


Description: Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization.

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3.8.1 Definition:

Initial Patient Population:

o AND: "Patient Characteristic Birthdate: birth date" >= 6 month(s) starts before start of "Measurement

Period" o AND:

OR: Count >= 2 of:


OR: "Encounter, Performed: Outpatient Consultation"

OR: "Encounter, Performed: Care Services in Long-Term Residential Facility"


OR: "Encounter, Performed: Patient Provider Interaction"

OR: Count >= 1 of:

OR: "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17"


OR: "Encounter, Performed: Preventive Care Services-Individual Counseling"

OR: "Encounter, Performed: Preventive Care Services - Group Counseling"

OR: "Encounter, Performed: Preventive Care Services - Other"

OR: "Encounter, Performed: Discharge Services - Nursing Facility"

OR: "Encounter, Performed: Nursing Facility Visit"


OR: "Procedure, Performed: Peritoneal Dialysis"

OR: "Procedure, Performed: Hemodialysis"

OR: "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17"




Denominator:


o AND:

OR:

OR: "Encounter, Performed: Encounter-Influenza"



<= 92 day(s) starts before start of "Measurement Period"

OR:

OR: "Encounter, Performed: Encounter-Influenza"



<= 89 day(s) starts after start of "Measurement Period"

Numerator:

o AND:

OR:

OR: "Procedure, Performed: Influenza Vaccination"

OR: "Medication, Administered: Influenza Vaccine"

OR: "Communication: From Patient to Provider: Previous Receipt of Influenza Vaccine"


OR:

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OR: "Procedure, Performed: Influenza Vaccination"

OR: "Medication, Administered: Influenza Vaccine"

OR: "Communication: From Patient to Provider: Previous Receipt of Influenza Vaccine"


Denominator Exceptions:

o AND:

OR:

OR: "Communication: From Patient to Provider: Influenza Vaccination Declined"

OR:

OR: "Procedure, Performed not done: Medical Reason" for "Influenza Vaccination"

OR: "Procedure, Performed not done: Patient Reason" for "Influenza Vaccination"

OR: "Procedure, Performed not done: System Reason" for "Influenza Vaccination"

OR:

OR: "Medication, Administered not done: Medical Reason" for "Influenza Vaccine"

OR: "Medication, Administered not done: Patient Reason" for "Influenza Vaccine"

OR: "Medication, Administered not done: System Reason" for "Influenza Vaccine"


OR:

OR: "Communication: From Patient to Provider: Influenza Vaccination Declined"

OR:

OR: "Procedure, Performed not done: Medical Reason" for "Influenza Vaccination"

OR: "Procedure, Performed not done: Patient Reason" for "Influenza Vaccination"

OR: "Procedure, Performed not done: System Reason" for "Influenza Vaccination"

OR:

OR: "Medication, Administered not done: Medical Reason" for "Influenza Vaccine"

OR: "Medication, Administered not done: Patient Reason" for "Influenza Vaccine"

OR: "Medication, Administered not done: System Reason" for "Influenza Vaccine"


OR:

AND: "Occurrence A of Diagnosis, Active: Allergy to Eggs" starts before or during "Measurement Period"

AND NOT: "Occurrence A of Diagnosis, Active: Allergy to Eggs" <= 89 day(s) ends after

start of "Measurement Period"

OR:

AND: "Occurrence A of Diagnosis, Active: Allergy to Influenza Vaccine" starts before or


AND NOT: "Occurrence A of Diagnosis, Active: Allergy to Influenza Vaccine" <= 89 day(s)

ends after start of "Measurement Period"

OR:

AND: "Occurrence A of Diagnosis, Active: Intolerance to Influenza Vaccine" starts before or during "Measurement Period"

AND NOT: "Occurrence A of Diagnosis, Active: Intolerance to Influenza Vaccine" <= 89 day(s) ends after start of "Measurement Period"

OR:

AND: "Occurrence A of Procedure, Intolerance: Influenza Vaccination" starts before or


AND NOT: "Occurrence A of Procedure, Intolerance: Influenza Vaccination" <= 89 day(s)

ends after start of "Measurement Period"

OR:

AND: "Occurrence A of Medication, Intolerance: Influenza Vaccine" starts before or during "Measurement Period"

AND NOT: "Occurrence A of Medication, Intolerance: Influenza Vaccine" <= 89 day(s) ends after start of "Measurement Period"

OR:

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AND: "Occurrence A of Medication, Allergy: Influenza Vaccine" starts before or during

"Measurement Period"

AND NOT: "Occurrence A of Medication, Allergy: Influenza Vaccine" <= 89 day(s) ends after start of "Measurement Period"

3.8.2 Calculations: Initial Patient Population: Number of unique patients of age >= 6 months before the measurement period with the given Issuer(s) of Patient ID and for the given Facilities who has a two or more studies with a procedure with a code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'ENCOUNTER' AND CODESYSTEM = 'CPT' and SETNAME IN ('OFFICE VISIT', 'OUTPATIENT CONSULTATION', 'CARE SERVICES IN LONG-TERM RESIDENTIAL FACILITY', 'HOME HEALTHCARE SERVICES') or with a problem with a code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'ENCOUNTER' AND CODESYSTEM = ' SNOMEDCT' and SETNAME = 'PATIENT PROVIDER INTERACTION' with in the reporting period Or who has at least on study with a procedure with a code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'ENCOUNTER' AND CODESYSTEM = 'CPT' and SETNAME IN ('PREVENTIVE CARE SERVICES-INITIAL OFFICE VISIT, 18 AND UP', 'PREVENTIVE CARE- INITIAL OFFICE VISIT, 0 TO 17', 'PREVENTIVE CARE SERVICES-INDIVIDUAL COUNSELING', 'PREVENTIVE CARE SERVICES - GROUP COUNSELING', 'PREVENTIVE CARE SERVICES - OTHER', 'DISCHARGE SERVICES - NURSING FACILITY', 'NURSING FACILITY VISIT', 'PREVENTIVE CARE - ESTABLISHED OFFICE VISIT, 0 TO 17', 'PREVENTIVE CARE SERVICES - ESTABLISHED OFFICE VISIT, 18 AND UP') Or with a procedure with a code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'PROCEDURE' AND CODESYSTEM = 'CPT' and SETNAME IN ('PERITONEAL DIALYSIS', 'HEMODIALYSIS') Denominator: Number of patients in the initial patient population with studies between 92 days prior to the start date of the reporting period and 89 day after the start date of the report period with procedure with code name that matches in the MUVALUESET for the given CMSID with SETTYPE = ' PROCEDURE' AND CODESYSTEM = 'CPT' and SETNAME IN ('PERITONEAL DIALYSIS', 'HEMODIALYSIS') or with code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'ENCOUNTER' AND CODESYSTEM = 'CPT' and SETNAME = 'ENCOUNTER-INFLUENZA' Numerator: Number of patients in the denominator with studies between 153 days prior to the start date of the reporting period and 89 day after the start date of the report period with procedure with code name that matches in the MUVALUESET for the given CMSID with SETTYPE = ' PROCEDURE' AND CODESYSTEM = 'CPT' and SETNAME = 'INFLUENZA VACCINATION' or with code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'ENCOUNTER' AND CODESYSTEM = 'CPT' and SETNAME = 'ENCOUNTER-INFLUENZA' Or with vaccine with CVX code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'MEDICATION' AND CODESYSTEM = ' CVX' and SETNAME = 'INFLUENZA VACCINATION' Or problems with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'COMMUNICATION' AND CODESYSTEM = 'SNOMEDCT' and SETNAME = 'PREVIOUS RECEIPT OF INFLUENZA VACCINE'

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Denominator Exceptions: Patients with problem of code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM' AND CODESYSTEM = 'SNOMEDCT' AND SETNAME = 'INFLUENZA VACCINATION DECLINED' with the problem date between 153 days prior to the start date of the reporting period and 89 days after the start of the reporting period Or a with a study with study date between 153 days prior to the start date of the reporting period and 89 days after the start of the reporting period with a problem with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'ATTRIBUTE' AND CODESYSTEM = 'SNOMEDCT' and SETNAME IN ('MEDICAL REASON', 'PATIENT REASON', 'SYSTEM REASON') with problem date matching the study date and a procedure with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'PROCEDURE' AND CODESYSTEM = 'CPT' and SETNAME = ' INFLUENZA VACCINATION' or with a vaccine with CVX code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'MEDICATION' AND CODESYSTEM = ' CVX' and SETNAME = 'INFLUENZA VACCINE' with immunization date matches the study date. Or has a problem with problem code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM' AND CODESYSTEM = 'SNOMEDCT' and SETNAME IN ('ALLERGY TO EGGS', 'ALLERGY TO INFLUENZA VACCINE', 'INTOLERANCE TO INFLUENZA VACCINE') with the problem date is between the start and end dates of the reporting period. 3.9 Controlling High Blood Pressure


Description: Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period. 3.9.1 Definition: Initial Patient Population:


Period" o AND: "Patient Characteristic Birthdate: birth date" < 85 year(s) starts before start of "Measurement Period" o AND:

OR: "Occurrence A of Diagnosis, Active: Essential Hypertension" <= 6 month(s) starts after start of


OR:

AND: "Occurrence A of Diagnosis, Active: Essential Hypertension" starts before start of


AND NOT: "Occurrence A of Diagnosis, Active: Essential Hypertension" ends before start of

"Measurement Period" o AND:








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Denominator:



o AND:

OR:

AND: "Occurrence A of Diagnosis, Active: Pregnancy" starts before or during "Measurement

Period"

AND NOT: "Occurrence A of Diagnosis, Active: Pregnancy" ends before start of


OR:

AND: "Occurrence A of Diagnosis, Active: End Stage Renal Disease" starts before or during "Measurement Period"

AND NOT: "Occurrence A of Diagnosis, Active: End Stage Renal Disease" ends before start of "Measurement Period"

OR:

AND: "Occurrence A of Diagnosis, Active: Chronic Kidney Disease, Stage 5" starts before or


AND NOT: "Occurrence A of Diagnosis, Active: Chronic Kidney Disease, Stage 5" ends

before start of "Measurement Period"

OR:

OR: "Procedure, Performed: Vascular Access for Dialysis"

OR: "Encounter, Performed: ESRD Monthly Outpatient Services"

OR: "Procedure, Performed: Kidney Transplant"

OR: "Procedure, Performed: Dialysis Services"

OR: "Intervention, Performed: Other Services Related to Dialysis"

OR: "Intervention, Performed: Dialysis Education"

starts before or during "Measurement Period

Numerator:

o AND:

AND: "Physical Exam, Finding: Diastolic Blood Pressure (result < 90 mmHg)"

AND: "Physical Exam, Finding: Systolic Blood Pressure (result < 140 mmHg)"

during MOST RECENT:


OR: "Encounter, Performed: Outpatient Consultation"







3.9.2 Calculations:

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Initial Patient Population: Number of unique patients of age >= 18 and age < 85 before the measurement period with the given Issuer(s) of Patient ID and for the given Facilities who has a study with a diagnosis with a code name that matches in the MUVALUESET for the given CMSID with SETTYPE = ' CONDITION-DIAGNOSIS-PROBLEM' AND CODESYSTEM in ('ICD10CM', 'ICD9CM') and SETNAME = ' ESSENTIAL HYPERTENSION' and with the study date within 6 months from the start of the reporting period and a study with a procedure code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'ENCOUNTER' AND CODESYSTEM = ‘CPT' and SETNAME IN ('OFFICE VISIT', 'HOME HEALTHCARE SERVICES', 'PREVENTIVE CARE SERVICES-INITIAL OFFICE VISIT, 18 AND UP', 'PREVENTIVE CARE SERVICES - ESTABLISHED OFFICE VISIT, 18 AND UP') with the study date within the reporting period or the patient has a problem with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'ENCOUNTER' AND CODESYSTEM = ‘SNOMEDCT' and SETNAME = ‘FACE-TO-FACE INTERACTION' with the problem date within the reporting period. Denominator: Same as Initial Patient Population. Denominator Exclusions: Patients with study with a diagnosis of code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM' AND CODESYSTEM IN ('ICD10CM','ICD9CM') AND SETNAME IN ('PREGNANCY', 'END STAGE RENAL DISEASE', 'CHRONIC KIDNEY DISEASE, STAGE 5') Or study with a procedure code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'PROCEDURE' AND CODESYSTEM = ’CPT’ AND SETNAME IN ('VASCULAR ACCESS FOR DIALYSIS', 'KIDNEY TRANSPLANT', 'DIALYSIS SERVICES') OR SETTYPE = ' ENCOUNTER' AND CODESYSTEM = ’CPT’ AND SETNAME = 'ESRD MONTHLY OUTPATIENT SERVICES' Or with problem of code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'INTERVENTION' AND CODESYSTEM = ' SNOMEDCT' AND SETNAME IN ('OTHER SERVICES RELATED TO DIALYSIS', 'DIALYSIS EDUCATION') with problem date before the end of the reporting period. Numerator: Number of patients in the denominator who have a lab result with a code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'PHYSICAL EXAM' AND CODESYSTEM= 'LOINC' AND SETNAME = 'DIASTOLIC BLOOD PRESSURE' and with the result < 90 mmHg and lab result with a code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'PHYSICAL EXAM' AND CODESYSTEM= 'LOINC' AND SETNAME = 'SYSTOLIC BLOOD PRESSURE' and with the result < 140 mmHg and has a procedure with code name that matches in the MUVALUESET for the given CMSID with SETTYPE = ' ENCOUNTER' AND CODESYSTEM= 'CPT' AND SETNAME IN ('OFFICE VISIT', 'OUTPATIENT CONSULTATION', 'HOME HEALTHCARE SERVICES', 'PREVENTIVE CARE SERVICES-INITIAL OFFICE VISIT, 18 AND UP', 'PREVENTIVE CARE SERVICES - ESTABLISHED OFFICE VISIT, 18 AND UP') or with a problem with problem code that matches in the MUVALUESET for the given CMSID with SETTYPE = ' ENCOUNTER' AND CODESYSTEM= ' SNOMEDCT' AND SETNAME = 'FACE-TO-FACE INTERACTION'. 3.10 Use of Imaging Studies for Low Back Pain


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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. 3.10.1 Definition:

Initial Patient Population:

AND: FIRST: "Occurrence A of Diagnosis, Active: Low Back Pain" starts during "Measurement Period"


Period" o AND: "Patient Characteristic Birthdate: birth date" < 50 year(s) starts before start of "Measurement Period" o AND:

OR: "Occurrence A of Diagnosis, Active: Low Back Pain" starts during ("Encounter, Performed:

Office Visit" <= 337 day(s) starts after start of "Measurement Period")

OR: "Occurrence A of Diagnosis, Active: Low Back Pain" starts during ("Encounter, Performed: Emergency Department Visit" <= 337 day(s) starts after start of "Measurement Period")

OR: "Occurrence A of Diagnosis, Active: Low Back Pain" starts during ("Encounter, Performed: Face-to-Face Interaction" <= 337 day(s) starts after start of "Measurement Period")

Denominator:



o AND:

OR: "Diagnosis, Active: Low Back Pain" <= 180 day(s) starts before start of "Occurrence A of

Diagnosis, Active: Low Back Pain"

OR:

OR: "Diagnosis, Active: All Cancer"

OR: "Diagnosis, Inactive: All Cancer"

OR: "Diagnosis, Resolved: All Cancer"

starts before or during "Measurement Period"

OR:

OR: "Diagnosis, Active: Trauma"

OR: "Diagnosis, Active: IV Drug Abuse"

OR: "Diagnosis, Active: Neurologic impairment"

<= 365 day(s) starts before or during "Measurement Period"

Numerator:

o AND NOT:

OR: "Diagnostic Study, Performed: X-Ray of Lower Spine"

OR: "Diagnostic Study, Performed: MRI of Lower Spine"

OR: "Diagnostic Study, Performed: CT Scan of Lower Spine"

<= 28 day(s) starts after start of "Occurrence A of Diagnosis, Active: Low Back Pain"

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3.10.2 Calculations: Initial Patient Population: Number of unique patients of age >= 18 and age < 50 before the measurement period with the given Issuer(s) of Patient ID and for the given Facilities who has at least one study with a diagnosis with a code name that matches in the MUVALUESET for the given CMSID with SETTYPE = ' CONDITION-DIAGNOSIS-PROBLEM' AND CODESYSTEM in ('ICD10CM', 'ICD9CM') and SETNAME = 'LOW BACK PAIN' and with the study date within the reporting period and the study is the first visit with the reporting period and on studies between reporting period start date and 337 days after reporting period start date which has a procedure with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'ENCOUNTER' AND CODESYSTEM = ‘CPT' and SETNAME IN ('OFFICE VISIT', 'EMERGENCY DEPARTMENT VISIT') or the patient has a problem with code that matches in the MUVALUESET for the given CMSID with SETTYPE = 'ENCOUNTER' AND CODESYSTEM = ‘SNOMEDCT' and SETNAME = ‘FACE-TO-FACE INTERACTION' with the problem date that matches the study date. Denominator: Same as Initial Patient Population. Denominator Exclusions: Patients with study with a diagnosis of code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM' AND CODESYSTEM IN ('ICD10CM','ICD9CM') AND SETNAME = 'LOW BACK PAIN' and has another study with same diagnosis code within <= 180 days of the study or with a study with diagnosis of code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM' AND CODESYSTEM IN ('ICD10CM','ICD9CM') AND SETNAME = 'ALL CANCER' Or with a study with diagnosis of code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM' AND CODESYSTEM IN ('ICD10CM','ICD9CM') AND SETNAME = 'ALL CANCER' or with a study with diagnosis of code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM' AND CODESYSTEM IN ('ICD10CM','ICD9CM') AND SETNAME = 'ALL CANCER' and study date less than the end of the reporting period Or with a study with diagnosis of code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'CONDITION-DIAGNOSIS-PROBLEM' AND CODESYSTEM IN ('ICD10CM','ICD9CM') AND SETNAME IN ('TRAUMA', 'IV DRUG ABUSE', 'NEUROLOGIC IMPAIRMENT') and study date is between 365 days prior to the start of the reporting period and the end of the reporting period. Numerator: Number of patients in the denominator who do not have a lab result with a code name that matches in the MUVALUESET for the given CMSID with SETTYPE = 'DIAGNOSTIC STUDY' AND CODESYSTEM= 'LOINC' AND SETNAME IN ('X-RAY OF LOWER SPINE', 'MRI OF LOWER SPINE', 'CT SCAN OF LOWER SPINE') and with the order date is within 28 days of the study date.

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4 REFERENCES

http://www.healthit.gov/sites/default/files/170.314g12numrec_automeascalc_2014_tp_v1.7.pdf http://www.healthit.gov/sites/default/files/cypress_test_procedure_12042013.pdf

http://www.healthit.gov/sites/default/files/170.314g12numrec_automeascalc_2014_tp_v1.7.pdf

http://www.healthit.gov/sites/default/files/cypress_test_procedure_12042013.pdf

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VERSIONS Version Revision Notes Updated by Reviewed by Effective Date

Rev. A Initial update for 6.0 RSA LBX 07/10/2015

Rev. B Update for 6.0 PRU-3 JJE SRN 01/08/2016

Documents

Meaningful Measures and Clinical Quality Measures...2 Meaningful Use Measures 2.1 Computerized Provider Order Entry (CPOE) Objective: Use computerized provider order entry for medication,