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Clinical Quality Measures Reports Quick Start Guide

Overview
These Reports deal specifically with Clinical Quality Measurements for Meaningful Use, PQRS, and MACRA programs.

Layout
Here is an overview of every Report available under Clinical Quality Measures.

Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
This Report measures the percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified.

Anti-depressant Medication Management
This Report measures the percentage of patients 18 years of age and older who were diagnoses with major depression and treated with antidepressant medication, and who remained on antidepressant medication treatment.

Appropriate Treatment for Children with Upper Respiratory Infection (URI)
This Report measures the percentage of children 3 months - 18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode.

Breast Cancer Screening
This Report measures the percentage of women 40-69 years of age who had a mammogram to screen for breast cancer.

Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer
This Report measures the percentage of female patients aged 18 years and older with Stage IC through IIIC, ER, or PR positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12-month reporting period.

Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
This Report measures the percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best- corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery.

Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures
This Report measures the percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had a cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong IOL, retinal detachment, or wound dehiscence.

Cervical Cancer Screening
This Report measures the percentage of women 23-64 years of age, who received one or more Pap tests to screen for cervical cancer.

Child and Adolescent Major Depressive Disorder: Suicide Risk Assessment
This Report measures percentage of patient visits for those patients aged 6-17 years with a diagnosis of major depressive disorder with an assessment for suicide risk.

Childhood Immunization Status
This Report measures the 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.

Children Who Have Dental Decay or Cavities
This Report measures the percentage of children, ages 0-20 years, who have had tooth decay or cavities during the measurement period.

Chlamydia Screening for Women
This Report measures the percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period.

Closing the Referral Loop: Receipt of Specialist Report
This Report measures the percentage of patients with referrals, regardless of age, for whom the referring provider receives a report from the provider to whom the patient was referred.

Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients
This Report measures the percentage of patients aged 18 through 80 years with AJCC Stage III colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy, or have previously received adjuvant chemotherapy within the 12-month reporting period.

Colorectal Cancer Screening
This Report measures the percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer.

Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)
This Report measures the percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have a prior MI or a current or prior LVEF <40% who were prescribed beta-blocker therapy.

Dementia: Cognitive Assessment
This Report measures the percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period.

Depression Remission at Twelve Months
This Report measures adult patients age 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at twelve months defined as PHQ-9 score less than 5.

Diabetes: Eye Exam
This Report measures the percentage of patients 18-75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period.

Diabetes: Foot Exam
This Report measure the percentage of patients aged 18-75 years of age with diabetes who had a foot exam during the measurement period.

Diabetes: Hemoglobin A1c Poor Control
This Report measures the percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.

Diabetes: Low Density Lipoprotein (LDL) Management
This Report measures the percentage of patients 18-75 years of age with diabetes whose LDL-C was adequately controlled (<100 mg/dL) during the measurement period.

Diabetes: Urine Protein Screening
This Report measures the percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period.

Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
This Report measures the percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months.

Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity or Retinopathy
This Report measures the percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months.

Documentation of Current Medications in the Medical Record
This Report measures the percentage of specified visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications to the best of his/her knowledge and ability.

Falls: Screening for Future Fall Risk
This Report measures the percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.

Functional Status Assessment for Hip Replacement
This Report measures the percentage of patients aged 18 years and older with primary total hip arthroplasty (THA) who completed baseline and follow-up (patient-reported) functional status assessments.

Functional Status Assessment for Knee Replacement
This Report measures the percentage of patients aged 18 years and older with primary total knee arthroplasty (TKA) who completed baseline and follow-up (patient-reported) functional status assessments.

Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
This Report measures the percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge.

Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
This Report measures the percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge.

Hemoglobin A1c Test for Pediatric Patients
This Report measures the percentage of patients 5-17 years of age with diabetes with an HbA1c test during the measurement period.

HIV/AIDS: Medical Visit
This Report measures the percentage of patients, regardless of age, with a diagnosis of HIV/AIDS with at least two medical visits during the measurement year with a minimum of 90 days between each visit.

HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis
This Report measures the percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis Jiroveci Pneumonia (PCP) prochylaxis.

HIV/AIDS: RNA Control for Patients with HIV
This Report measures the percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS, with at least two visits during the measurement year, with at least 90 days between each visit, whose most recent HIV RNA level is <200 copies/mL.

Hypertension: Improvement in Blood Pressure
This Report measures the percentage of patients aged 18-85 years of ago with a diagnosis of hypertension whose blood pressure improved during the measurement period.

Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
This Report measures the percentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following: Two rates are reported- a) Percentage of patients who initiated treatment within 14 days of the diagnosis. b) Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit.

Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control
This Report measures the percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had a complete lipid profile performed during the measurement period and whose LDL-C was adequately controlled (< 100 mg/dL).

Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic
This Report measures the percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who’ve had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antithrombotic during the measurement period.

Maternal Depression Screening
This Report measures the percentage of children who turned 6 months of age during the measurement year, who had a face-to-face visit between the clinician and the child during child's first 6 months, and who had a maternal depression screening for the mother at least once between 0 and 6 months of life.

Oncology: Medical and Radiation - Pain Intensity Quantified
This Report measures the percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified.

Pneumonia Vaccination Status for Older Adults
This Report measures the percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.

Pregnant women that had HBsAg testing
This Report identifies pregnant women who had a HBsAg (hepatitis B) test during their pregnancy.

Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
This Report measures the percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
This Report measures the percentage of patients aged 18 years and older with an encounter during the reporting period with a documented calculated BMI during the encounter or during the previous six months AND when the BMI is outside of normal parameters, follow-up plan is documented during the encounter or during the previous 6 months of the encounter with the BMI outside of normal parameters.

Preventive Care and Screening: Cholesterol - Fasting Low Density Lipoprotein (LDL- C) Test Performed
This Report measures the Percentage of patients aged 20 through 79 years whose risk factors have been assessed and a fasting LDL-C test has been performed.

Preventive Care and Screening: Risk-Stratified Cholesterol Fasting Low Density Lipoprotein (LDL- C)
This Report measures the percentage of patients aged 20 through 79 years who had a fasting LDL-C test performed and whose risk-stratified fasting LDL-C is at or below the recommended LDL-C goal.

Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
This Report measures the Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen.

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
This Report measures the 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.

Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists
This Report measures the percentage of children, age 0-20 years, who received a fluoride varnish application during the measurement period.

Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
This Report measures the percentage of patients aged 18 years and older with a diagnosis of POAG who have an optic nerve head evaluation during one or more office visits within 12 months.

Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
This Report measures the percentage of patients, regardless of age, with a diagnosis of prostate cancer at low risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since the diagnosis of prostate cancer.

Use of Appropriate Medications for Asthma
The Report measures the percentage of patients 5-64 years of age who were identified as having persistent asthma and were appropriately prescribed medication during the measurement period.

Use of High-Risk Medications in the Elderly
This Report measures the percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported.

Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
This Report measures the percentage of patients 3-17 years of age who’ve had an outpatient visit with a Primary Care Physicians (PCP) or Obstetrician/Gynecologist (OB/GYN) and who have had evidence of the following during the measurement period: Three rates are reported; 1- Percentage of patients with height, weight, and body mass index 2- Percentage of patients with counseling for nutrition 3- Percentage of patients with counseling for physical activity.

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