2011 Edition General Criteria (170.302)  |  2011 Edition Ambulatory Criteria (170.304)  |  2011 Edition Ambulatory Clinical Quality Measures  |  2011 Edition Inpatient Criteria (170.306)  |  2011 Edition Inpatient Clinical Quality Measures  |  2014 Edition Certification Criteria (170.314)  |  2014 Edition Ambulatory Clinical Quality Measures  |  2014 Edition Inpatient Clinical Quality Measures  |  2014 Edition CQM Domains  |  Capability Tags

2011 Edition General Criteria (170.302)
(a) Drug-drug, drug-allergy interaction checks
Drug-drug, drug-allergy interaction checks. (1) Notifications. Automatically and electronically generate and indicate in real-time, notifications at the point of care for drug-drug and drug-allergy contraindications based on medication list, medication allergy list, and computerized provider order entry (CPOE). (2) Adjustments. Provide certain users with the ability to adjust notifications provided for drug-drug and drug-allergy interaction checks.
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(b) Drug formulary checks
Drug formulary checks. Enable a user to electronically check if drugs are in a formulary or preferred drug list.
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(c) Maintain up-to-date problem list
Maintain up-to-date problem list. Enable a user to electronically record, modify, and retrieve a patient's problem list for longitudinal care in accordance with: (1) The standard specified in §170.207(a)(1); or (2) At a minimum, the version of the standard specified in §170.207(a)(2).
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(d) Maintain active medication list
Maintain active medication list. Enable a user to electronically record, modify, and retrieve a patient's active medication list as well as medication history for longitudinal care.
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(e) Maintain active medication allergy list
Maintain active medication allergy list. Enable a user to electronically record, modify, and retrieve a patient's active medication allergy list as well as medication allergy history for longitudinal care.
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(f) Record and chart vital signs
170.302(f)(1) Record and Chart Vital signs. Enable a user to electronically record, modify, and retrieve a patient's vital signs including, at a minimum, the height, weight, and blood pressure. 170.302(f)(2) Calculate Body mass index. Automatically calculate and display body mass index (BMI) based on a patient's height and weight. 170.302(f)(3) Plot and display growth charts. Plot and electronically display, upon request, growth charts for patients 2-20 years old.
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(g) Smoking status
Smoking status. Enable a user to electronically record, modify, and retrieve the smoking status of a patient. Smoking status types must include: current every day smoker; current some day smoker; former smoker; never smoker; smoker, current status unknown; unknown if ever smoked.
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(h) Incorporate laboratory test results
Incorporate laboratory test results. 1) Receive results. Electronically receive clinical laboratory test results in a structured format and display such results in human readable format. 2) Display test report information. Electronically display all the information for a test report specified at 42 CFR 493.1291(c)(1) through (7). 3) Incorporate results. Electronically attribute, associate, or link a laboratory test result to a laboratory order or patient record.
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(i) Generate patient lists
Generate patient lists. Enable a user to electronically select, sort, retrieve, and generate lists of patients according to, at a minimum, the data elements included in: (1) Problem list; (2) Medication list; (3) Demographics; and (4) Laboratory test results.
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(j) Medication reconciliation
Medication reconciliation. Enable a user to electronically compare two or more medication lists.
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(k) Submission to immunization registries
Submission to immunization registries. Electronically record, modify, retrieve, and submit immunization information in accordance with: (1) the standard (and applicable implementation specifications) specified in §170.205(e)(1) or §170.205(e)(2); and (2) At a minimum, the version of the standard specified in §170.207(e).
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(l) Public health surveillance
Public health surveillance. Electronically record, modify, retrieve, and submit syndrome-based public health surveillance information in accordance with the standard (and applicable implementation specifications) specified in §170.205(d)(1) or §170.205(d)(2).
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(m) Patient specific education resources
Patient specific education resources. Enable a user to electronically identify and provide patient-specific education resources according to, at a minimum, the data elements included in the patient's problem list; medication list; and laboratory test results as well as provide such resources to the patient.
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(n) Automated measure calculation
Automated measure calculation. For each meaningful use objective with a percentage-based measure, electronically record the numerator and denominator and generate a report including the numerator, denominator, and resulting percentage associated with each applicable meaningful use measure.
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(o) Access control
Access control. Assign a unique name and/or number for identifying and tracking user identity and establish controls that permit only authorized users to access electronic health information.
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(p) Emergency access
Emergency access. Permit authorized users (who are authorized for emergency situations) to access electronic health information during an emergency.
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(q) Automatic log-off
Automatic log-off. Terminate an electronic session after a predetermined time of inactivity.
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(r) Audit log
Audit log. (1) Record Actions. Record actions related to electronic health information in accordance with the standard specified in 170.210(b). (2) Generate audit log. Enable a user to generate an audit log for a specific time period and to sort entries in the audit log according to any of the elements specified in the standard at 170.210(b).
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(s) Integrity
Integrity. (1) Create a message digest in accordance with the standard specified in 170.210(c). (2) Verify in accordance with the standard specified in 170.210(c) upon receipt of electronically exchanged health information that such information has not been altered. (3) Detection. Detect the alteration of audit logs.
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(t) Authentication
Authentication. Verify that a person or entity seeking access to electronic health information is the one claimed and is authorized to access such information.
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(u) General encryption
General encryption. Encrypt and decrypt electronic health information in accordance with the standard specified in §170.210(a)(1), unless the Secretary determines that the use of such algorithm would pose a significant security risk for Certified EHR Technology.
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(v) Encryption when exchanging electronic health information
Encryption when exchanging electronic health information. Encrypt and decrypt electronic health information when exchanged in accordance with the standard specified in §170.210(a)(2).
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(w) Accounting of disclosures (optional)
Accounting of disclosures (optional). Record disclosures made for treatment, payment, and healthcare operations in accordance with the standards specified in §170.210(d).
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2011 Edition Ambulatory Criteria (170.304)
(a) Computerized provider order entry
Computerized provider order entry. Enable a user to electronically record, store, retrieve, and modify, at a minimum, the following order types: (1) Medications; (2) Laboratory; and (3) Radiology/imaging
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(b) Electronic prescribing
Electronic prescribing. Enable a user to electronically generate and transmit prescriptions and prescription-related information in accordance with: (1) The standard specified in §170.205(b)(1) or §170.205(b)(2); and (2) The standard specified in §170.207(d).
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(c) Record demographics
Record demographics. Enable a user to electronically record, modify, and retrieve patient demographic data including preferred language, gender, race, ethnicity, and date of birth. Enable race and ethnicity to be recorded in accordance with the standard specified at §170.207(f).
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(d) Patient reminders
Patient reminders. Enable a user to electronically generate a patient reminder list for preventive or follow-up care according to patient preferences based on, at a minimum, the data elements included in: Problem list; Medication list; Medication allergy list; Demographics; and Laboratory test results
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(e) Clinical decision support
Clinical decision support. (1) Implement rules. Implement automated, electronic clinical decision support rules (in addition to drug-drug and drug-allergy contraindication checking) based on the data elements included in: problem list; medication list; demographics; and laboratory test results. (2) Notifications. Automatically and electronically generate and indicate in real-time, notifications and care suggestions based upon clinical decision support rules.
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(f) Electronic copy of health information
Electronic copy of health information. Enable a user to create an electronic copy of a patient's clinical information, including, at a minimum, diagnostic test results, problem list, medication list, and medication allergy list in: (1) Human readable format; and (2) On electronic media or through some other electronic means in accordance with: (i) The standard (and applicable implementation specifications) specified in §170.205(a)(1) or §170.205(a)(2); and (ii) For the following data elements the applicable standard must be used: (A) Problems. The standard specified in §170.207(a)(1) or, at a minimum, the version of the standard specified in §170.207(a)(2); (B) Laboratory test results. At a minimum, the version of the standard specified in §170.207(c); and (C) Medications. The standard specified in §170.207(d).
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(g) Timely access
Timely access. Enable a user to provide patients with online access to their clinical information, including, at a minimum, lab test results, problem list, medication list, and medication allergy list.
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(h) Clinical summaries
Clinical summaries. Enable a user to provide clinical summaries to patients for each office visit that include, at a minimum, diagnostic test results, problem list, medication list, and medication allergy list. If the clinical summary is provided electronically it must be: (1) Provided in human readable format; and (2) Provided on electronic media or through some other electronic means in accordance with: (i) The standard (and applicable implementation specifications) specified in §170.205(a)(1) or §170.205(a)(2); and (ii) For the following data elements the applicable standard must be used: (A) Problems. The standard specified in §170.207(a)(1) or, at a minimum, the version of the standard specified in §170.207(a)(2); (B)Laboratory test results. At a minimum, the version of the standard specified in §170.207(c); and (C) Medications. The standard specified in §170.207(d).
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(i) Exchange clinical information and patient summary record
Exchange clinical information and patient summary record. (1) Electronically receive and display. Electronically receive and display a patient's summary record, from other providers and organizations including, at a minimum, diagnostic tests results, problem list, medication list, and medication allergy list in accordance with the standard (and applicable implementation specifications) specified in §170.205(a)(1) or §170.205(a)(2). Upon receipt of a patient summary record formatted in the alternative standard, display it in human readable format. (2) Electronically transmit. Enable a user to electronically transmit a patient summary record to other providers and organizations including, at a minimum, diagnostic test results, problem list, medication list, and medication allergy list in accordance with: (i) The standard (and applicable implementation specifications) specified in §170.205(a)(1) or §170.205(a)(2); and (ii) For the following data elements the applicable standard must be used: (A) Problems. The standard specified in §170.207(a)(1) or, at a minimum, the version of the standard specified in §170.207(a)(2); (B) Laboratory test results. At a minimum, the version of the standard specified in §170.207(c); and (C) Medications. The standard specified in §170.207(d).
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(j) Calculate and submit clinical quality measures
Calculate and submit clinical quality measures. (1) Calculate. (i) Electronically calculate all of the core clinical measures specified by CMS for eligible professionals. (ii) Electronically calculate, at a minimum, three clinical quality measures specified by CMS for eligible professionals, in addition to those clinical quality measures specified in paragraph (1)(i). (2) Submission. Enable a user to electronically submit calculated clinical quality measures in accordance with the standard and implementation specifications specified in §170.205(f).
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2011 Edition Ambulatory Clinical Quality Measures
NQF 0001 Asthma Assesment
Title: Asthma Assessment Description: Percentage of patients aged 5 through 40 years with a diagnosis of asthma and who have been seen for at least 2 office visits, who were evaluated during at least one office visit within 12 months for the frequency (numeric) of daytime and nocturnal asthma symptoms.
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NQF 0002 Pharyngitis- Children
Title: Appropriate Testing for Children with Pharyngitis Description: Percentage of children 2-18 years of age who were diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode.
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NQF 0004 Alcohol and Drug Dependence
Title: Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: (a) Initiation, (b) Engagement Description: The percentage of adolescent and adult patients with a new episode of alcohol and other drug (AOD) dependence who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis and who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit.
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NQF 0012 Prenatal Care: HIV Screening
Title: Prenatal Care: Screening for Human Immunodeficiency Virus (HIV) Description: Percentage of patients, regardless of age, who gave birth during a 12-month period who were screened for HIV infection during the first or second prenatal care visit.
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NQF 0013 Hypertension: Blood Pressure Measurement
Title: Hypertension: Blood Pressure Measurement Description: Percentage of patient visits for patients aged 18 years and older with a diagnosis of hypertension who have been seen for at least 2 office visits, with blood pressure (BP) recorded.
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NQF 0014 Prenatal Care: Anti-D immune Globulin
Title: Prenatal Care: Anti-D Immune Globulin Description: Percentage of D (Rh) negative, unsensitized patients, regardless of age, who gave birth during a 12-month period who received anti-D immune globulin at 26-30 weeks gestation.
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NQF 0018 Controlling High Blood Pressure
Title: Controlling High Blood Pressure Description: The percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose BP was adequately controlled during the measurement year
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NQF 0024 Youth Weight Assesment
Title: Weight Assessment and Counseling for Children and Adolescents Description: Percentage of patients 2 -17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or OB/GYN and who had evidence of BMI percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year.
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NQF 0027 Tobacco Use Cessation
Title: Smoking and Tobacco Use Cessation, Medical assistance: a. Advising Smokers and Tobacco Users to Quit, b. Discussing Smoking and Tobacco Use Cessation Medications, c. Discussing Smoking and Tobacco Use Cessation Strategies Description: Percentage of patients 18 years of age and older who were current smokers or tobacco users, who were seen by a practitioner during the measurement year and who received advice to quit smoking or tobacco use or whose practitioner recommended or discussed smoking or tobacco use cessation medications, methods or strategies.
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NQF 0028 Prevenitive Care: Tobacco Use Assesment and Cessation
Title: Preventive Care and Screening Measure Pair: a. Tobacco Use Assessment, b. Tobacco Cessation Intervention Description: Percentage of patients aged 18 years and older who have been seen for at least 2 office visits who were queried about tobacco use one or more times within 24 months b. Percentage of patients aged 18 years and older identified as tobacco users within the past 24 months and have been seen for at least 2 office visits, who received cessation intervention.
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NQF 0031 Breast Cancer Screening
Title: Breast Cancer Screening Description: Percentage of women 40-69 years of age who had a mammogram to screen for breast cancer.
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NQF 0032 Cervical Cancer Screening
Title: Cervical Cancer Screening Description: Percentage of women 21-64 years of age, who received one or more Pap tests to screen for cervical cancer
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NQF 0033 Chlamydia Screening for Women
Title: Chlamydia Screening for Women Description: Percentage of women 15- 24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year.
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NQF 0034 Colorectal Cancer Screening
Title: Colorectal Cancer Screening Description: Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer.
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NQF 0036 Appropriate Medications for Asthma
Title: Use of Appropriate Medications for Asthma Description: Percentage of patients 5 - 50 years of age who were identified as having persistent asthma and were appropriately prescribed medication during the measurement year. Report three age stratifications (5-11 years, 12-50 years, and total).
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NQF 0038 Childhood Immunization Status
Title: Childhood Immunization Status 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); two H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); two hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine and nine separate combination rates.
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NQF 0041 Influenza Immunization
Title: Preventive Care and Screening: Influenza Immunization for Patients ? 50 Years Old Description: Percentage of patients aged 50 years and older who received an influenza immunization during the flu season (September through February).
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NQF 0043 Pnemonia Vaccination
Title: Pneumonia Vaccination Status for Older Adults Description: Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.
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NQF 0047 Asthma Pharmacologic Therapy
Title: Asthma Pharmacologic Therapy Description: Percentage of patients aged 5 through 40 years with a diagnosis of mild, moderate, or severe persistent asthma who were prescribed either the preferred long-term control medication (inhaled corticosteroid) or an acceptable alternative treatment.
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NQF 0052 Use of Imaging Study: Low Back Pain
Title: Low Back Pain: Use of Imaging Studies Description: Percentage of patients with a primary diagnosis of low back pain who did not have an imaging study (plain x-ray, MRI, CT scan) within 28 days of diagnosis.
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NQF 0055 Diabetes: Eye Exam
Title: Diabetes: Eye Exam Description: Percentage of patients 18 -75 years of age with diabetes (type 1 or type 2) who had a retinal or dilated eye exam or a negative retinal exam (no evidence of retinopathy) by an eye care professional.
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NQF 0056 Diabetes: Foot Exam
Title: Diabetes: Foot Exam Description: The percentage of patients aged 18 - 75 years with diabetes (type 1 or type 2) who had a foot exam (visual inspection, sensory exam with monofilament, or pulse exam).
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NQF 0059 Diabetes Control: Hemoglobin A1c >9.0%
Title: Diabetes: Hemoglobin A1c Poor Control Description: Percentage of patients 18 - 75 years of age with diabetes (type 1 or type 2) who had hemoglobin A1c > 9.0%.
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NQF 0061 Diabetic Patients who elevated mmhg V140/90
Title: Diabetes: Blood Pressure Management Description: Percentage of patients 18 - 75 years of age with diabetes (type 1 or type 2) who had blood pressure <140/90 mmHg.
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NQF 0062 Nephropathy Screening- Urine
Title: Diabetes: Urine Screening Description: Percentage of patients 18 - 75 years of age with diabetes (type 1 or type 2) who had a nephropathy screening test or evidence of nephropathy.
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NQF 0064 Diabetes Control: LDL < 100mg/dl
Title: Diabetes: Low Density Lipoprotein (LDL) Management and Control Description: Percentage of patients 18-75 years of age with diabetes (type 1 or type 2) who had LDL-C < 100 mg/dL).
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NQF 0067 Antiplatelet Therapy
Title: Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD Description: Percentage of patients aged 18 years and older with a diagnosis of CAD who were prescribed oral antiplatelet therapy.
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NQF 0068 Ischemic Vascular Disease: Asparin or other Antithrombotic
Title: Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic Description: 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 transluminal coronary angioplasty (PTCA) from January 1-November 1 of the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the year prior to the measurement year and who had documentation of use of aspirin or another antithrombotic during the measurement year.
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NQF 0070 Coronoary Artery Disease: Beta Blocker Therapy Post Myocadial Infarction
Title: Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) Description: Percentage of patients aged 18 years and older with a diagnosis of CAD and prior MI who were prescribed beta-blocker therapy.
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NQF 0073 Blood Pressure Management: Ischemic Valve Disease
Title: Ischemic Vascular Disease (IVD): Blood Pressure Management Description: 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 transluminal coronary angioplasty (PTCA) from January 1- November 1 of the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the measurementyear and the year prior to the measurement year and whose recent blood pressure is in control (<140/90 mmHg).
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NQF 0074 Corinary Artery Disease: Lipid Lowering Therapy
Title: Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol Description: Percentage of patients aged 18 years and older with a diagnosis of CAD who were prescribed a lipid-lowering therapy (based on current ACC/AHA guidelines).
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NQF 0075 IVD: Complete Lipid Panel and LDL Control
Title: Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control. Description: 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 transluminal angioplasty (PTCA) from January 1-November1 of the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the year prior to the measurement year and who had a complete lipid profile performed during the measurement year and whose LDL-C<100 mg/dL.
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NQF 0081 Heart Failure: ACE/ ARB Therapy For LVSD (LVEF <40%)
Title: Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) Description: Percentage of patients aged 18 years and older with a diagnosis of heart failure and LVSD (LVEF< 40%) who were prescribed ACE inhibitor or ARB therapy.
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NQF 0083 Heart Failure: Beta Blocker for LVSD
Title: Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Description: Percentage of patients aged 18 years and older with a diagnosis of heart failure who also have LVSD (LVEF < 40%) and who were prescribed beta- blocker therapy.
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NQF 0084 Heart Failure: Warfarin Therapy
Title: Heart Failure (HF): Warfarin Therapy Patients with Atrial Fibrillation Description: Percentage of all patients aged 18 years and older with a diagnosis of heart failure and paroxysmal or chronic atrial fibrillation who were prescribed warfarin therapy.
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NQF 0086 Primary Open Angle Glaucoma
Title: Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation Description: Percentage of patients aged 18 years and older with a diagnosis of POAG who have been seen for at least two office visits who have an optic nerve head evaluation during one or more office visits within 12 months.
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NQF 0088 Diabetic Retinopathy: Macular Edema
Title: Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy Description: Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months.
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NQF 0089 Diabetes Management: Retinopathy Screening
Title: Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care Description: Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months.
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NQF 0105 Depression Management
Title: Anti-depressant medication management: (a) Effective Acute Phase Treatment,(b)Effective Continuation Phase Treatment Description: The percentage of patients 18 years of age and older who were diagnosed with a new episode of major depression, treated with antidepressant medication, and who remained on an antidepressant medication treatment.
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NQF 0385 Colon Cancer: Chemotherapy
Title: Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients Description: Percentage of patients aged 18 years and older with Stage IIIA through IIIC colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy, or have previously received adjuvant chemotherapy within the 12-month reporting period.
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NQF 0387 Breast Cancer: Hormonal Therapy
Title: Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer Description: 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.
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NQF 0389 Prostate Cancer: Avoid overuse of Bone Scan
Title: Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients Description: Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer.
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NQF 0421 Adult Weight Screening
Title: Adult Weight Screening and Follow-Up Description: Percentage of patients aged 18 years and older with a calculated BMI in the past six months or during the current visit documented in the medical record AND if the most recent BMI is outside parameters, a follow-up plan is documented.
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NQF 0575 Diabetes Control: Hemoglobin A1c <8.0%
Title: Diabetes: Hemoglobin A1c Control (<8.0%). Description: The percentage of patients 18-75 years of age with diabetes (type 1 or type 2) who had hemoglobin A1c <8.0%.
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2011 Edition Inpatient Criteria (170.306)
(a) Computerized provider order entry
Computerized provider order entry. Enable a user to electronically record, store, retrieve, and modify, at a minimum, the following order types: (1) Medications; (2) Laboratory; and (3) Radiology/Imaging
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(b) Record demographics
Record demographics. Enable a user to electronically record, modify, and retrieve patient demographic data including preferred language, gender, race, ethnicity, date of birth, and date and preliminary cause of death in the event of mortality. Enable race and ethnicity to be recorded in accordance with the standard specified at §170.207(f).
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(c) Clinical decision support
Clinical decision support. (1) Implement rules. Implement automated, electronic clinical decision support rules (in addition to drug-drug and drug-allergy contraindication checking) based on the data elements included in: problem list; medication list; demographics; and laboratory test results. (2) Notifications. Automatically and electronically generate and indicate in real-time, notifications and care suggestions based upon clinical decision support rules.
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(d) Electronic copy of health information
170.306(d)(1) Electronic copy of health information. (1) Enable a user to create an electronic copy of a patient's clinical information, including, at a minimum, diagnostic test results, problem list, medication list, medication allergy list, and procedures: (i) In human readable format; and (ii) On electronic media or through some other electronic means in accordance with: (A) The standard (and applicable implementation specifications) specified in §170.205(a)(1) or §170.205(a)(2); and (B) For the following data elements the applicable standard must be used: (1) Problems. The standard specified in §170.207(a)(1) or, at a minimum, the version of the standard specified in §170.207(a)(2); (2) Procedures. The standard specified in §170.207(b)(1) or §170.207(b)(2); (3) Laboratory test results. At a minimum, the version of the standard specified in §170.207(c); and (4) Medications. The standard specified in §170.207(d). 170.306 (d)(2)Electronic copy of health information Note: For discharge summary. (2) Enable a user to create an electronic copy of a patient's discharge summary in human readable format and on electronic media or through some other electronic means
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(e) Electronic copy of discharge instructions
Electronic copy of discharge instructions. Enable a user to create an electronic copy of the discharge instructions for a patient, in human readable format, at the time of discharge on electronic media or through some other electronic means.
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(f) Exchange clinical information and patient summary record
Exchange clinical information and patient summary record. (1) Electronically receive and display. Electronically receive and display a patient's summary record from other providers and organizations including, at a minimum, diagnostic test results, problem list, medication list, medication allergy list, and procedures in accordance with the standard (and applicable implementation specifications) specified in §170.205(a)(1) or §170.205(a)(2). Upon receipt of a patient summary record formatted in the alternative standard, display it in human readable format. (2) Electronically transmit. Enable a user to electronically transmit a patient's summary record to other providers and organizations including, at a minimum, diagnostic results, problem list, medication list, medication allergy list, and procedures in accordance with: (i) The standard (and applicable implementation specifications) specified in §170.205(a)(1) or §170.205(a)(2); and (ii) For the following data elements the applicable standard must be used: (A) Problems. The standard specified in §170.207(a)(1) or, at a minimum, the version of the standard specified in §170.207(a)(2); (B) Procedures. The standard specified in §170.207(b)(1) or §170.207(b)(2); (C) Laboratory test results. At a minimum, the version of the standard specified in §170.207(c); and (D) Medications. The standard specified in §170.207(d).
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(g) Reportable lab results
Reportable lab results. Electronically record, modify, retrieve, and submit reportable clinical lab results in accordance with the standard (and applicable implementation specifications) specified in §170.205(c) and, at a minimum, the version of the standard specified in §170.207(c).
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(h) Advance directives
Advance directives. Enable a user to electronically record whether a patient has an advance directive.
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(i) Calculate and submit clinical quality measures
Calculate and submit clinical quality measures. (1) Calculate. Electronically calculate all of the clinical quality measures specified by CMS for eligible hospitals and critical access hospitals. (2) Submission. Enable a user to electronically submit calculated clinical quality measures in accordance with the standard and implementation specifications specified in §170.205(f).
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2011 Edition Inpatient Clinical Quality Measures
NQF 0371 Venous Thromboembolism prophlaxis within 24 hours
Title: VTE prophylaxis within 24 hours of arrival. Description: This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission. Measure Developer: The Joint Commission
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NQF 0372 Intensive Care Unit Venous Thromboembolism prophylaxis
Title: Intensive Care Unit VTE prophylaxis. Description: This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after the initial admission (or transfer) to the Intensive Care Unit (ICU) or surgery end date for surgeries that start the day of or the day after ICU admission (or transfer). Measure Developer: The Joint Commission
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NQF 0373 VTE-3 VTE Patients with Anticoagulation OverlapTherapy
Title: Anticoagulation overlap therapy. Description: This measure assesses the number of patients diagnosed with confirmed VTE who received an overlap of parenteral (intravenous [IV] or subcutaneous [subcu]) anticoagulation and warfarin therapy. For patients who received less than five days of overlap therapy, they must be discharged on both medications. Overlap therapy must be administered for at least five days with an international normalized ratio (INR) > or = 2 prior to discontinuation of the parenteral anticoagulation therapy or the patient must be discharged on both medications. Measure Developer: The Joint Commission
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NQF 0374 VTE-4 VTE Patients Receiving Unfractionated Heparin (UFH) with Dosages/Platelet Count Monitoring by
Title: Platelet monitoring on unfractionated heparin. Description: This measure assesses the number of patients diagnosed with confirmed VTE who received intravenous (IV) UFH therapy dosages AND had their platelet counts monitored using defined parameters such as a nomogram or protocol. Measure Developer: The Joint Commission
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NQF 0375 VTE-5 VTE discharge instructions
Title: VTE discharge instructions. Description: This measure assesses the number of patients diagnosed with confirmed VTE that are discharged to home, to home with home health, home hospice or discharged/transferred to court/law enforcement on warfarin with written discharge instructions that address all four criteria: compliance issues, dietary advice, follow-up monitoring, and information about the potential for adverse drug reactions/interactions. Measure Developer: The Joint Commission
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NQF 0376 VTE-6 Incidence of potentially preventable VTE
Title: Incidence of potentially preventable VTE. Description: This measure assesses the number of patients diagnosed with confirmed VTE during hospitalization (not present on arrival) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date. Measure Developer: The Joint Commission
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NQF 0435 Stroke: Discharge on anti-thrombotics
Title: Ischemic stroke -- Discharge on anti-thrombotics Description: Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge Measure Developer: The Joint Commission
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NQF 0436 Ischemic Stroke- Anticoagulation for A-fib/flutter
Title: Ischemic stroke -- Anticoagulation for A-fib/flutter Description: Ischemic stroke patients with atrial fibrillation/flutter who are prescribed anticoagulation therapy at hospital discharge. Measure Developer: The Joint Commission
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NQF 0437 Ischemic Stroke - Thrombolytic therapy
Title: Ischemic stroke -- Thrombolytic therapy for patients arriving within 2 hours of symptom onset Description: Acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well and for whom IV t-PA was initiated at this hospital within 3 hours of time last known well. Measure Developer: The Joint Commission
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NQF 0438 Ischemic or Hemorrhagic stroke- Antothrombotic therapy
Title: Ischemic or hemorrhagic stroke -- Antithrombotic therapy by day 2 Description: Ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2. Measure Developer: The Joint Commission
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NQF 0439 Ischemic stroke- Discharge on statins
Title: Ischemic stroke -- Discharge on statins. Description: Ischemic stroke patients with LDL > or = 100 mg/dL, or LDL not measured, or, who were on a lipidlowering medication prior to hospital arrival are prescribed statin medication at hospital discharge. Measure Developer: The Joint Commission
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NQF 0440 Ischemic or Hemorrhagic Stroke- Stroke education
Title: Ischemic or hemorrhagic stroke -- Stroke education. Description: Ischemic or hemorrhagic stroke patients or their caregivers who were given educational materials during the hospital stay addressing all of the following: activation of emergency medical system, need for follow-up after discharge, medications prescribed at discharge, risk factors for stroke, and warning signs and symptoms of stroke. Measure Developer: The Joint Commission
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NQF 0441 Ischemic or Hemorrhagic Stroke- Rehabilitation assesment
Title: Ischemic or hemorrhagic stroke -- Rehabilitation assessment Description: Ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services. Measure Developer: The Joint Commission
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NQF 0495 Emergency Department Throughput - Arrival to Departure
Title: Emergency Department Throughput -- admitted patients Median time from ED arrival to ED departure for admitted patients Description: Median time from emergency department arrival to time of departure from the emergency room for patients admitted to the facility from the emergency department Measure Developer: CMS/Oklahoma Foundation for Medical Quality (OFMQ)
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NQF 0497 Emergency Department Throughput - Admission to Inpatient
Title: Emergency Department Throughput -- admitted patients. Admission decision time to ED departure time for admitted patients Description: Median time from admit decision time to time of departure from the emergency department of emergency department patients admitted to inpatient status Measure Developer: CMS/OFMQ
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2014 Edition Certification Criteria (170.314)
(a)(1) Computerized Provider Order Entry
Computerized provider order entry. Enable a user to electronically record, change, and access the following order types, at a minimum: (i) Medications; (ii) Laboratory; and (iii) Radiology/imaging.
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(a)(2) Drug-Drug, Drug-Allergy Interaction Checks
Drug-drug, drug-allergy interaction checks. (i) Interventions. Before a medication order is completed and acted upon during computerized provider order entry (CPOE), interventions must automatically and electronically indicate to a user drug-drug and drug-allergy contraindications based on a patient’s medication list and medication allergy list. (ii) Adjustments. (A) Enable the severity level of interventions provided for drug-drug interaction checks to be adjusted. (B) Limit the ability to adjust severity levels to an identified set of users or available as a system administrative function.
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(a)(3) Demographics
Demographics. (i) Enable a user to electronically record, change, and access patient demographic data including preferred language, sex, race, ethnicity, and date of birth. (A) Enable race and ethnicity to be recorded in accordance with the standard specified in § 170.207(f) and whether a patient declines to specify race and/or ethnicity. (B) Enable preferred language to be recorded in accordance with the standard specified in § 170.207(g) and whether a patient declines to specify a preferred language. (ii) Inpatient setting only. Enable a user to electronically record, change, and access preliminary cause of death in the event of a mortality.
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(a)(4) Vital signs, body mass index, and growth charts
Vital signs, body mass index, and growth charts. (i) Vital signs. Enable a user to electronically record, change, and access, at a minimum, a patient’s height/length, weight, and blood pressure. Height/length, weight, and blood pressure must be recorded in numerical values only. (ii) Calculate body mass index. Automatically calculate and electronically display body mass index based on a patient’s height and weight. (iii) Optional—Plot and display growth charts. Plot and electronically display, upon request, growth charts for patients.
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(a)(5) Problem List
Problem list. Enable a user to electronically record, change, and access a patient’s active problem list: (i) Ambulatory setting. Over multiple encounters in accordance with, at a minimum, the version of the standard specified in § 170.207(a)(3); or (ii) Inpatient setting. For the duration of an entire hospitalization in accordance with, at a minimum, the version of the standard specified in § 170.207(a)(3).
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(a)(6) Medication List
Medication list. Enable a user to electronically record, change, and access a patient’s active medication list as well as medication history: (i) Ambulatory setting. Over multiple encounters; or (ii) Inpatient setting. For the duration of an entire hospitalization.
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(a)(7) Medication Allergy List
Medication allergy list. Enable a user to electronically record, change, and access a patient’s active medication allergy list as well as medication allergy history: (i) Ambulatory setting. Over multiple encounters; or (ii) Inpatient setting. For the duration of an entire hospitalization.
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(a)(8) Clinical Decision Support
Clinical decision support. (i) Evidence-based decision support interventions. Enable a limited set of identified users to select (i.e., activate) one or more electronic clinical decision support interventions (in addition to drug-drug and drug-allergy contraindication checking) based on each one and at least one combination of the following data: (A) Problem list; (B) Medication list; (C) Medication allergy list; (D) Demographics; (E) Laboratory tests and values/results; and (F) Vital signs. (ii) Linked referential clinical decision support. (A) EHR technology must be able to: (1) Electronically identify for a user diagnostic and therapeutic reference information; or (2) Electronically identify for a user diagnostic and therapeutic reference information in accordance with the standard specified at § 170.204(b) and the implementation specifications at § 170.204 (b)(1) or (2). (B) For paragraph (a)(8)(ii)(A) of this section, EHR technology must be able to electronically identify for a user diagnostic or therapeutic reference information based on each one and at least one combination of the following data referenced in paragraphs (a)(8)(i)(A) through (F) of this section: (iii) Clinical decision support configuration. (A) Enable interventions and reference resources specified in paragraphs (a)(8)(i) and (ii) of this section to be configured by a limited set of identified users (e.g., system administrator) based on a user’s role. (B) EHR technology must enable interventions to be electronically triggered: (1) Based on the data referenced in paragraphs (a)(8)(i)(A) through (F) of this section. (2) When a patient’s medications, medication allergies, and problems are incorporated from a transition of care/referral summary received pursuant to paragraph (b)(1)(iii) of this section. (3) Ambulatory setting only. When a patient’s laboratory tests and values/results are incorporated pursuant to paragraph (b)(5)(i)(A)(1) of this section. (iv) Automatically and electronically interact. Interventions triggered in accordance with paragraphs (a)(8)(i) through (iii) of this section must automatically and electronically occur when a user is interacting with EHR technology. (v) Source attributes. Enable a user to review the attributes as indicated for all clinical decision support resources: (A) For evidence-based decision support interventions under paragraph (a)(8)(i) of this section: (1) Bibliographic citation of the intervention (clinical research/guideline); (2) Developer of the intervention (translation from clinical research/guideline); (3) Funding source of the intervention development technical implementation; and (4) Release and, if applicable, revision date(s) of the intervention or reference source. (B) For linked referential clinical decision support in paragraph (a)(8)(ii) of this section and drug-drug, drug-allergy interaction checks in paragraph(a)(2) of this section, the developer of the intervention, and where clinically indicated, the bibli
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(a)(9) Electronic Notes
Electronic notes. Enable a user to electronically record, change, access, and search electronic notes.
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(a)(10) Drug-Formulary Checks
Drug-formulary checks. EHR technology must automatically and electronically check whether a drug formulary (or preferred drug list) exists for a given patient and medication.
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(a)(11) Smoking Status
Smoking status. Enable a user to electronically record, change, and access the smoking status of a patient in accordance with the standard specified at § 170.207(h).
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(a)(12) Image Results
Image results. Electronically indicate to a user the availability of a patient’s images and narrative interpretations (relating to the radiographic or other diagnostic test(s)) and enable electronic access to such images and narrative interpretations.
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(a)(13) Family Health History
Family health history. Enable a user to electronically record, change, and access a patient’s family health history according to: (i) At a minimum, the version of the standard specified in § 170.207(a)(3); or (ii) The standard specified in § 170.207(j).
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(a)(14) Patient List Creation
Patient list creation. Enable a user to electronically and dynamically select, sort, access, and create patient lists by: date and time; and based on each one and at least one combination of the following data: (i) Problems; (ii) Medications; (iii) Medication allergies; (iv) Demographics; (v) Laboratory tests and values/results; and (vi) Ambulatory setting only. Patient communication preferences.
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(a)(15) Patient-Specific Education Resources
Patient-specific education resources. EHR technology must be able to electronically identify for a user patient-specific education resources based on data included in the patient's problem list, medication list, and laboratory tests and values/results: (i) In accordance with the standard specified at § 170.204(b) and the implementation specifications at § 170.204(b)(1) or (2); and (ii) By any means other than the method specified in paragraph (a)(15)(i) of this section.
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(a)(16) Electronic Medication Administration Record
Electronic medication administration record. (i) In combination with an assistive technology that provides automated information on the “rights� specified in paragraphs (a)(16)(i)(A) through (E) of this section, enable a user to electronically verify the following before administering medication(s): (A) Right patient. The patient to whom the medication is to be administered matches the medication to be administered. (B) Right medication. The medication to be administered matches the medication ordered for the patient. (C) Right dose. The dose of the medication to be administered matches the dose of the medication ordered for the patient. (D) Right route. The route of medication delivery matches the route specified in the medication order. (E) Right time. The time that the medication was ordered to be administered compared to the current time. (ii) Right documentation. Electronically record the time and date in accordance with the standard specified in § 170.210(g), and user identification when a medication is administered.
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(a)(17) Advance Directives
Advance directives. Enable a user to electronically record whether a patient has an advance directive.
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(b)(1) Transitions of Care - receive, display, and incorporate transition of care/referral summaries
Transitions of care – receive, display, and incorporate transition of care/referral summaries. (i) Receive. EHR technology must be able to electronically receive transition of care/referral summaries in accordance with: (A) The standard specified in § 170.202(a). (B) Optional. The standards specified in § 170.202(a) and (b). (C) Optional. The standards specified in § 170.202(b) and (c). (ii) Display. EHR technology must be able to electronically display in human readable format the data included in transition of care/referral summaries received and formatted according to any of the following standards (and applicable implementation specifications) specified in: § 170.205(a)(1), § 170.205(a)(2), and § 170.205(a)(3). (iii) Incorporate. Upon receipt of a transition of care/referral summary formatted according to the standard adopted at § 170.205(a)(3), EHR technology must be able to: (A) Correct patient. Demonstrate that the transition of care/referral summary received is or can be properly matched to the correct patient. (B) Data incorporation. Electronically incorporate the following data expressed according to the specified standard(s): (1) Medications. At a minimum, the version of the standard specified in § 170.207(d)(2); (2) Problems. At a minimum, the version of the standard specified in § 170.207(a)(3); (3) Medication allergies. At a minimum, the version of the standard specified in § 170.207(d)(2). (C) Section views. Extract and allow for individual display each additional section or sections (and the accompanying document header information) that were included in a transition of care/referral summary received and formatted in accordance with the standard adopted at § 170.205(a)(3).
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(b)(2) Transitions of Care - create and transmit transition of care/referral summaries
Transitions of care – create and transmit transition of care/referral summaries. (i) Create. Enable a user to electronically create a transition of care/referral summary formatted according to the standard adopted at § 170.205(a)(3) that includes, at a minimum, the Common MU Data Set and the following data expressed, were applicable, according to the specified standard(s): (A) Encounter diagnoses. The standard specified in § 170.207(i) or, at a minimum, the version of the standard specified § 170.207(a)(3); (B) Immunizations. The standard specified in § 170.207(e)(2); (C) Cognitive status; (D) Functional status; and (E) Ambulatory setting only. The reason for referral; and referring or transitioning provider’s name and office contact information. (F) Inpatient setting only. Discharge instructions. (ii) Transmit. Enable a user to electronically transmit the transition of care/referral summary created in paragraph (b)(2)(i) of this section in accordance with: (A) The standard specified in § 170.202(a). (B) Optional. The standards specified in § 170.202(a) and (b).(C) Optional. The standards specified in § 170.202(b) and (c).
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(b)(3) Electronic Prescribing
Electronic prescribing. Enable a user to electronically create prescriptions and prescription related information for electronic transmission in accordance with: (i) The standard specified in § 170.05(b)(2); and (ii) At a minimum, the version of the standard specified in § 170.207(d)(2).
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(b)(4) Clinical Information Reconciliation
Clinical information reconciliation. Enable a user to electronically reconcile the data that represent a patient’s active medication, problem, and medication allergy list as follows. For each list type: (i) Electronically and simultaneously display (i.e., in a single view) the data from at least two list sources in a manner that allows a user to view the data and their attributes, which must include, at a minimum, the source and last modification date. (ii) Enable a user to create a single reconciled list of medications, medication allergies, or problems. (iii) Enable a user to review and validate the accuracy of a final set of data and, upon a user’s confirmation, automatically update the list.
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(b)(5) Incorporate Laboratory Tests and Values/Results
Incorporate laboratory tests and values/results. (i) Receive results. (A) Ambulatory setting only. (1) Electronically receive and incorporate clinical laboratory tests and values/results in accordance with the standard specified in § 170.205(j) and, at a minimum, the version of the standard specified in § 170.207(c)(2). (2) Electronically display the tests and values/results received in human readable format. (B) Inpatient setting only. Electronically receive clinical laboratory tests and values/results in a structured format and electronically display such tests and values/results in human readable format. (ii) Electronically display all the information for a test report specified at 42 CFR 493.1291(c)(1) through (7). (iii) Electronically attribute, associate, or link a laboratory test and value/result with a laboratory order or patient record.
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(b)(6) Transmission of Electronic Laboratory Tests and Values/Results to Ambulatory Providers
Transmission of electronic laboratory tests and values/results to ambulatory providers. EHR technology must be able to electronically create laboratory test reports for electronic transmission in accordance with the standard specified in § 170.205(j) and with laboratory tests expressed in accordance with, at a minimum, the version of the standard specified in § 170.207(c)(2).
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(b)(7) Data Portability
Data portability. Enable a user to electronically create a set of export summaries for all patients in EHR technology formatted according to the standard adopted at § 170.205(a)(3) that represents the most current clinical information about each patient and includes, at a minimum, the Common MU Data Set and the following data expressed, where applicable, according to the specified standard(s): (i) Encounter diagnoses. The standard specified in § 170.207(i) or, at a minimum, the version of the standard at § 170.207(a)(3); (ii) Immunizations. The standard specified in § 170.207(e)(2); (iii) Cognitive status; (iv) Functional status; and (v) Ambulatory setting only. The reason for referral; and referring or transition in provider’s name and office contact information. (vi) Inpatient setting only. Discharge instructions.
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(c)(1) Clinical Quality Measures - capture and export
Clinical Quality Measures – capture and export. (i) Capture. For each and every CQM for which the EHR technology is presented for certification, EHR technology must be able to electronically record all of the data identified in the standard specified at § 170.204(c) that would be necessary to calculate each CQM. Data required for CQM exclusions or exceptions must be codified entries, which may include specific terms as defined by each CQM, or may include codified expressions of “patient reason,� “system reason,� or “medical reason.� (ii) Export. EHR technology must be able to electronically export a data file formatted in accordance with the standards specified at § 170.205(h) that includes all of the data captured for each and every CQM to which EHR technology was certified under paragraph (c)(1)(i) of this section.
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(c)(2) Clinical Quality Measures - import and calculate
Clinical quality measures – import and calculate. (i) Import. EHR technology must be able to electronically import a data file formatted in accordance with the standard specified at § 170.205(h) and use such data to perform the capability specified in paragraph (c)(2)(ii) of this section. EHR technology presented for certification to all three of the certification criteria adopted in paragraphs (c)(1) through (3) of this section is not required to meet paragraph (c)(2)(i). (ii) Calculate. EHR technology must be able to electronically calculate each and every clinical quality measure for which it is presented for certification.
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(c)(3) Clinical Quality Measures - electronic submission
Clinical quality measures – electronic submission. Enable a user to electronically create a data file for transmission of clinical quality measurement data: (i) In accordance with the standards specified at § 170.205(h) and (k); and (ii) That can be electronically accepted by CMS.
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(d)(1) Authentication, access control, and authorization
Authentication, access control, and authorization. (i) Verify against a unique identifier(s) (e.g., username or number) that a person seeking access to electronic health information is the one claimed; and (ii) Establish the type of access to electronic health information a user is permitted based on the unique identifier(s) provided in paragraph (d)(1)(i) of this section, and the actions the user is permitted to perform with the EHR technology.
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(d)(2) Auditable Events and Tamper-Resistance
Auditable events and tamper-resistance. (i) Record actions. EHR technology must be able to: (A) Record actions related to electronic health information in accordance with the standard specified in § 170.210(e)(1); (B) Record the audit log status (enabled or disabled) in accordance with the standard specified in § 170.210(e)(2) unless it cannot be disabled by any user; and (C) Record the encryption status (enabled or disabled) of electronic health information locally stored on end-user devices by EHR technology in accordance with the standard specified in § 170.210(e)(3) unless the EHR technology prevents electronic health information from being locally stored on end-user devices (see 170.314(d)(7) of this section). (ii) Default setting. EHR technology must be set by default to perform the capabilities specified in paragraph (d)(2)(i)(A) of this section and, where applicable, paragraphs (d)(2)(i)(B) or (C), or both paragraphs (d)(2)(i)(B) and (C). (iii) When disabling the audit log is permitted. For each capability specified in paragraphs (d)(2)(i)(A) through (C) of this section that EHR technology permits to be disabled, the ability to do so must be restricted to a limited set of identified users. (iv) Audit log protection. Actions and statuses recorded in accordance with paragraph (d)(2)(i) of this section must not be capable of being changed, overwritten, or deleted by the EHR technology. (v) Detection. EHR technology must be able to detect whether the audit log has been altered.
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(d)(3) Audit Report(s)
Audit report(s). Enable a user to create an audit report for a specific time period and to sort entries in the audit log according to each of the data specified in the standards at § 170.210(e).
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(d)(4) Amendments
Amendments. Enable a user to electronically select the record affected by a patient’s request for amendment and perform the capabilities specified in paragraphs (d)(4)(i) or (ii) of this section. (i) Accepted amendment. For an accepted amendment, append the amendment to the affected record or include a link that indicates the amendment’s location. (ii) Denied amendment. For a denied amendment, at a minimum, append the request and denial of the request to the affected record or include a link that indicates this information’s location.
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(d)(5) Automatic log-off
Automatic log-off. Prevent a user from gaining further access to an electronic session after a predetermined time of inactivity.
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(d)(6) Emergency access
Emergency access. Permit an identified set of users to access electronic health information during an emergency.
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(d)(7) End-User Device Encryption
End-user device encryption. Paragraph (d)(7)(i) or (ii) of this section must be met to satisfy this certification criterion. (i) EHR technology that is designed to locally store electronic health information on end-user devices must encrypt the electronic health information stored on such devices after use of EHR technology on those devices stops. (A) Electronic health information that is stored must be encrypted in accordance with the standard specified in § 170.210(a)(1). (B) Default setting. EHR technology must be set by default to perform this capability and, unless this configuration cannot be disabled by any user, the ability to change the configuration must be restricted to a limited set of identified users. (ii) EHR technology is designed to prevent electronic health information from being locally stored on end-user devices after use of EHR technology on those devices stops.
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(d)(8) Integrity
Integrity. (i) Create a message digest in accordance with the standard specified in § 170.210(c). (ii) Verify in accordance with the standard specified in § 170.210(c) upon receipt of electronically exchanged health information that such information has not been altered.
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(d)(9) Accounting of Disclosures (optional)
Accounting of disclosures. Record disclosures made for treatment, payment, and health care operations in accordance with the standard specified in § 170.210(d).
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(e)(1) View, Download, and Transmit to 3rd Party
View, download, and transmit to 3rd party. (i) EHR technology must provide patients (and their authorized representatives) with an online means to view, download, and transmit to a 3rd party the data specified below. Access to these capabilities must be through a secure channel that ensures all content is encrypted and integrity-protected in accordance with the standard for encryption and hashing algorithms specified at § 170.210(f). (A) View. Electronically view in accordance with the standard adopted at § 170.204(a), at a minimum, the following data: (1) The Common MU Data Set (which should be in their English (i.e., non-coded) representation if they associate with a vocabulary/code set). (2) Ambulatory setting only. Provider’s name and office contact information. (3) Inpatient setting only. Admission and discharge dates and locations; discharge instructions; and reason(s) for hospitalization. (B) Download. (1) Electronically download an ambulatory summary or inpatient summary (as applicable to the EHR technology setting for which certification is requested) in human readable format or formatted according to the standard adopted at § 170.205(a)(3) that includes, at a minimum, the following data (which, for the human readable version, should be in their English representation if they associate with a vocabulary/code set): (i) Ambulatory setting only. All of the data specified in paragraph (e)(1)(i)(A)(1) and (2) of this section. (ii) Inpatient setting only. All of the data specified in paragraphs (e)(1)(i)(A)(1) and (3) of this section. (2) Inpatient setting only. Electronically download transition of care/referral summaries that were created as a result of a transition of care (pursuant to the capability expressed in the certification criterion adopted at paragraph (b)(2) of this section). (C) Transmit to third party. (1) Electronically transmit the ambulatory summary or inpatient summary (as applicable to the EHR technology setting for which certification is requested) created in paragraph (e)(1)(i)(B)(1) of this section in accordance with the standard specified in § 170.202(a). (2) Inpatient setting only. Electronically transmit transition of care/referral summaries (as a result of a transition of care/referral) selected by the patient (or their authorized representative) in accordance with the standard specified in § 170.202(a). (ii) Activity history log. (A) When electronic health information is viewed, downloaded, or transmitted to a third-party using the capabilities included in paragraphs (e)(1)(i)(A) through (C) of this section, the following information must be recorded and made accessible to the patient: (1) The action(s) (i.e., view, download, transmission) that occurred; (2) The date and time each action occurred in accordance with the standard specified at § 170.210(g); and (3) The user who took the action. (B) EHR technology presented for certification may demonstrate compliance with paragraph (e)(1)(ii)(A) of this section
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(e)(2) Clinical Summary
Clinical summary. (i) Create. Enable a user to create a clinical summary for a patient in human readable format and formatted according to the standards adopted at § 170.205(a)(3). (ii) Customization. Enable a user to customize the data included in the clinical summary. (iii) Minimum data from which to select. EHR technology must permit a user to select, at a minimum, the following data when creating a clinical summary: (A) Common MU Data Set (which, for the human readable version, should be in their English representation if they associate with a vocabulary/code set) (B) The provider’s name and office contact information; date and location of visit; reason for visit; immunizations and/or medications administered during the visit; diagnostic tests pending; clinical instructions; future appointments; referrals to other providers; future scheduled tests; and recommended patient decision aids.
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(e)(3) Secure Messaging
Secure messaging. Enable a user to electronically send messages to, and receive messages from, a patient in a manner that ensures: (i) Both the patient (or authorized representative) and EHR technology user are authenticated; and (ii) The message content is encrypted and integrity-protected in accordance with the standard for encryption and hashing algorithms specified at § 170.210(f).
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(f)(1) Immunization Information
Immunization information. Enable a user to electronically record, change, and access immunization information.
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(f)(2) Transmission to Immunization Registries
Transmission to immunization registries. EHR technology must be able to electronically create immunization information for electronic transmission in accordance with: (i) The standard and applicable implementation specifications specified in § 170.205(e)(3); and (ii) At a minimum, the version of the standard specified in § 170.207(e)(2).
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(f)(3) Transmission to Public Health Agencies - Syndromic Surveillance
Transmission to public health agencies – syndromic surveillance. EHR technology must be able to electronically create syndrome-based public health surveillance information for electronic transmission in accordance with: (i) Ambulatory setting only. (A) The standard specified in § 170.205(d)(2). (B) Optional. The standard (and applicable implementation specifications) specified in § 170.205(d)(3). (ii) Inpatient setting only. The standard (and applicable implementation specifications) specified in § 170.205(d)(3).
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(f)(4) Transmission of Reportable Laboratory Tests and Values/Results
Transmission of reportable laboratory tests and values/results. HER technology must be able to electronically create reportable laboratory tests and values/results for electronic transmission in accordance with: (i) The standard (and applicable implementation specifications) specified in § 170.205(g); and (ii) At a minimum, the versions of the standards specified in § 170.207(a)(3) and (c)(2).
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(f)(5) Cancer Case Information
Cancer case information. Enable a user to electronically record, change, and access cancer case information.
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(f)(6) Transmission to Cancer Registries
Transmission to cancer registries. EHR technology must be able to electronically create cancer case information for electronic transmission in accordance with: (i) The standard (and applicable implementation specifications) specified in § 170.205(i); and (ii) At a minimum, the versions of the standards specified in § 170.207(a)(3) and (c)(2).
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(g)(1) Automated Numerator Recording
Automated numerator recording. For each meaningful use objective with a percentage-based measure, EHR technology must be able to create a report or file that enables a user to review the patients or actions that would make the patient or action eligible to be included in the measure’s numerator. The information in the report or file created must be of sufficient detail such that it enables a user to match those patients or actions to meet the measure's denominator limitations when necessary to generate an accurate percentage.
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(g)(2) Automated Measure Calculation
Automated measure calculation. For each meaningful use objective with a percentage-based measure that is supported by a capability included in an EHR technology, electronically record the numerator and denominator and create a report including the numerator, denominator, and resulting percentage associated with each applicable meaningful use measure.
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(g)(3) Safety-Enhanced Design
Safety-enhanced design. User-centered design processes must be applied to each capability an EHR technology includes that is specified in the following certification criteria: § 170.314(a)(1), (2), (6) through (8), and (16) and (b)(3) and (4).
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(g)(4) Quality Management System
Quality management system. For each capability that an EHR technology includes and for which that capability's certification is sought, the use of a Quality Management System (QMS) in the development, testing, implementation and maintenance of that capability must be identified. (i) If a single QMS was used for applicable capabilities, it would only need to be identified once. (ii) If different QMS were applied to specific capabilities, each QMS applied would need to be identified. This would include the application of a QMS to some capabilities and none to others. (iii) If no QMS was applied to all applicable capabilities such a response is acceptable to satisfy this certification criterion.
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2014 Edition Ambulatory Clinical Quality Measures
CMS2 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
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.
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CMS22 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
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
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CMS50 Closing the referral loop: receipt of specialist report
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.
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CMS52 HIV/AIDS: Pneumocystis jiroveci pneumonia (PCP) Prophylaxis
Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis jiroveci pneumonia (PCP) prophylaxis
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CMS56 Functional status assessment for hip replacement
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.
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CMS61 Preventive Care and Screening: Cholesterol – Fasting Low Density Lipoprotein (LDL-C) Test Performed
Percentage of patients aged 20 through 79 years whose risk factors have been assessed and a fasting LDL-C test has been performed.
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CMS62 HIV/AIDS: Medical Visit
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 60 days between each visit
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CMS64 Preventive Care and Screening: Risk- Stratified Cholesterol – Fasting Low Density Lipoprotein (LDL-C)
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.
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CMS65 Hypertension: Improvement in blood pressure
Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period.
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CMS66 Functional status assessment for knee replacement
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.
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CMS68 Documentation of Current Medications in the Medical Record
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. This list must include ALL prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration.
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CMS69 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
Percentage of patients aged 18 years and older with a calculated BMI in the past six months or during the current reporting period documented in the medical record AND if the most recent BMI is outside of normal parameters, a follow-up plan is documented within the past six months or during the current reporting period. Normal Parameters: Age 65 years and older BMI - 23 and < 30 Age 18-64 years BMI - 18.5 and < 25
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CMS74 Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists
Percentage of children, age 0-20 years, who received a fluoride varnish application during the measurement period.
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CMS75 Children who have dental decay or cavities
Percentage of children ages 0-20, who have had tooth decay or cavities during the measurement period.
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CMS77 HIV/AIDS: RNA control for Patients with HIV
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 60 days between each visit, whose most recent HIV RNA level is <200 copies/mL.
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CMS82 Maternal depression screening
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.
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CMS90 Functional status assessment for complex chronic conditions
Percentage of patients aged 65 years and older with heart failure who completed initial and follow-up patient-reported functional status assessments
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CMS117 Childhood Immunization Status
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.
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CMS122 Diabetes: Hemoglobin A1c Poor Control
Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.
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CMS123 Diabetes: Foot Exam
Percentage of patients aged 18-75 years of age with diabetes who had a foot exam during the measurement period.
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CMS124 Cervical Cancer Screening
Percentage of women 21-64 years of age, who received one or more Pap tests to screen for cervical cancer.
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CMS125 Breast Cancer Screening
Percentage of women 40-69 years of age who had a mammogram to screen for breast cancer.
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CMS126 Use of Appropriate Medications for Asthma
Percentage of patients 5-64 years of age who were identified as having persistent asthma and were appropriately prescribed medication during the measurement period.
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CMS127 Pneumonia Vaccination Status for Older Adults
Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.
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CMS128 Anti-depressant Medication Management
Percentage of patients 18 years of age and older who were diagnosed with major depression and treated with antidepressant medication, and who remained on antidepressant medication treatment. Two rates are reported. a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks). b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).
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CMS129 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
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 diagnosis of prostate cancer
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CMS130 Colorectal Cancer Screening
Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer.
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CMS131 Diabetes: Eye Exam
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
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CMS132 Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures
Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had 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 power IOL, retinal detachment, or wound dehiscence.
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CMS133 Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
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.
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CMS134 Diabetes: Urine Protein Screening
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.
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CMS135 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
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
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CMS136 ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication
Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase. b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.
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CMS137 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
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.
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CMS138 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
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
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CMS139 Screening for Future Fall Risk
Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.
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CMS140 Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer
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
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CMS141 Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients
Percentage of patients aged 18 through 80 years with 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
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CMS142 Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
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
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CMS143 Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation
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
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CMS144 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
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
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CMS145 Coronary Artery Disease (CAD): Beta-Blocker Therapy- Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)
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
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CMS146 Appropriate Testing for Children with Pharyngitis
Percentage of children 2-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode.
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CMS147 Preventative Care and Screening: Influenza Immunization
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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CMS148 Hemoglobin A1c Test for Pediatric Patients
Percentage of patients 5-17 years of age with diabetes with an HbA1c test during the measurement period
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CMS149 Dementia: Cognitive Assessment
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.
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CMS153 Chlamydia Screening for Women
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.
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CMS154 Appropriate Treatment for Children with Upper Respiratory Infection (URI)
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.
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CMS155 Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported. 1. Percentage of patients with height, weight, and body mass index (BMI) percentile documentation 2. Percentage of patients with counseling for nutrition 3. Percentage of patients with counseling for physical activity
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CMS156 Use of High-Risk Medications in the Elderly
Percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported. a.    Percentage of patients who were ordered at least one high-risk medication. b.    Percentage of patients who were ordered at least two different high-risk medications.
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CMS157 Oncology: Medical and Radiation – Pain Intensity Quantified
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
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CMS158 Pregnant women that had HBsAg testing
This measure identifies pregnant women who had a HBsAg (hepatitis B) test during their pregnancy.
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CMS159 Depression Remission at Twelve Months
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. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment.
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CMS160 Depression Utilization of the PHQ-9 Tool
Adult patients age 18 and older with the diagnosis of major depression or dysthymia who have a PHQ-9 tool administered at least once during a 4 month period in which there was a qualifying visit.
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CMS161 Major Depressive Disorder (MDD): Suicide Risk Assessment
Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD who had a suicide risk assessment completed at each visit during the measurement period.
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CMS163 Diabetes: Low Density Lipoprotein (LDL) Management
Percentage of patients 18-75 years of age with diabetes whose LDL-C was adequately controlled (< 100 mg/dL) during the measurement period.
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CMS164 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic
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 documentation of use of aspirin or another antithrombotic during the measurement period.
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CMS165 Controlling High Blood Pressure
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.
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CMS166 Use of Imaging Studies for Low Back Pain
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.
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CMS167 Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy
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
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CMS169 Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use
Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use.
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CMS177 Child and Adolescent Major Depressive Disorder: Suicide Risk Assessment
Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk.
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CMS179 ADE Prevention and Monitoring: Warfarin Time in Therapeutic Range.
Average percentage of time in which individuals with atrial fibrillation who are on chronic anticoagulation have International Normalized Ratio (INR) test results within the therapeutic range during the measurement period.
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CMS182 Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control
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).
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2014 Inpatient Clinical Quality Measures
CMS9 Exclusive Breast Milk Feeding
Exclusive breast milk feeding during the newborn's entire hospitalization.
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CMS26 Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver
An assessment that there is documentation in the medical record that a Home Management Plan of Care (HMPC) document was given to the pediatric asthma patient/caregiver.
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CMS30 AMI-10 Statin Prescribed at Discharge
Acute Myocardial Infarction (AMI) patients who are prescribed a statin at hospital discharge.
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CMS31 EHDI-1a - Hearing screening prior to hospital discharge
This measure assesses the proportion of births that have been screened for hearing loss before hospital discharge.
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CMS32 ED-3-Median time from ED arrival to ED departure for discharged ED patients.
Median time from emergency department arrival to time of departure from the emergency room for patients discharged from the emergency department.
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CMS53 AMI-8a- Primary PCI Received Within 90 Minutes of Hospital Arrival
Acute myocardial infarction (AMI) patients with ST-segment elevation or LBBB on the ECG closest to arrival time receiving primary PCI during the hospital stay with a time from hospital arrival to PCI of 90 minutes or less.
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CMS55 Emergency Department (ED)-1 Emergency Department Throughput – Median time from ED arrival to ED departure for admitted ED patients
Median time from emergency department arrival to time of departure from the emergency room for patients admitted to the facility from the emergency department.
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CMS60 AMI-7a- Fibrinolytic Therapy Received Within 30 minutes of Hospital Arrival
Acute myocardial infarction (AMI) patients with ST-segment elevation or LBBB on the ECG closest to arrival time receiving fibrinolytic therapy during the hospital stay and having a time from hospital arrival to fibrinolysis of 30 minutes or less.
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CMS71 Stroke-3 Ischemic stroke – Anticoagulation Therapy for Atrial Fibrillation/Flutter
Ischemic stroke patients with atrial fibrillation/flutter who are prescribed anticoagulation therapy at hospital discharge.
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CMS72 Stroke-5 Ischemic stroke – Antithrombotic therapy by end of hospital day two
Ischemic stroke patients administered antithrombotic therapy by the end of hospital day two.
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CMS73 VTE-3 VTE Patients with Anticoagulation OverlapTherapy
This measure assesses the number of patients diagnosed with confirmed VTE who received an overlap of parenteral (intravenous [IV] or subcutaneous [subcu]) anticoagulation and warfarin therapy. For patients who received less than five days of overlap therapy, they must be discharged on both medications or have a reason for discontinuation of overlap therapy. Overlap therapy must be administered for at least five days with an international normalized ratio (INR) greater than or equal to 2 prior to discontinuation of the parenteral anticoagulation therapy, discharged on both medications or have a reason for discontinuation of overlap therapy.
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CMS91 Stroke-4 Ischemic stroke – Thrombolytic Therapy
Acute ischemic stroke patients who arrive at this hospital within 2 hours (120 minutes) of time last known well and for whom IV t-PA was initiated at this hospital within 3 hours (180 minutes) of time last known well.
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CMS100 AMI-2-Aspirin Prescribed at Discharge for AMI
Acute myocardial infarction (AMI) patients who are prescribed aspirin at hospital discharge.
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CMS102 Stroke-10 Ischemic or hemorrhagic stroke – Assessed for Rehabilitation
Ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services.
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CMS104 Stroke-2 Ischemic stroke – Discharged on anti-thrombotic therapy
Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge.
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CMS105 Stroke-6 Ischemic stroke – Discharged on Statin Medication
Ischemic stroke patients with LDL greater than or equal to 100 mg/dL, or LDL not measured, or, who were on a lipid-lowering medication prior to hospital arrival are prescribed statin medication at hospital discharge.
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CMS107 Stroke-8 Ischemic or hemorrhagic stroke – Stroke education
Ischemic or hemorrhagic stroke patients or their caregivers who were given educational materials during the hospital stay addressing all of the following: activation of emergency medical system, need for follow-up after discharge, medications prescribed at discharge, risk factors for stroke, and warning signs and symptoms of stroke.
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CMS108 Venous Thromboembolism (VTE)-1 VTE prophylaxis
This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission.
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CMS109 VTE-4 VTE Patients Receiving Unfractionated Heparin (UFH) with Dosages/Platelet Count Monitoring by Protocol (or Nomogram)
This measure assesses the number of patients diagnosed with confirmed VTE who received intravenous (IV) UFH therapy dosages AND had their platelet counts monitored using defined parameters such as a nomogram or protocol.
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CMS110 VTE-5 VTE discharge instructions
This measure assesses the number of patients diagnosed with confirmed VTE that are discharged to home, home care, court/law enforcement, or home on hospice care on warfarin with written discharge instructions that address all four criteria: compliance issues, dietary advice, follow-up monitoring, and information about the potential for adverse drug reactions/interactions.
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CMS111 ED-2 Emergency Department Throughput – admitted patients – Admit decision time to ED departure time for admitted patients
Median time (in minutes) from admit decision time to time of departure from the emergency department for emergency department patients admitted to inpatient status.
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CMS113 PC-01 Elective Delivery Prior to 39 Completed Weeks Gestation
Patients with elective vaginal deliveries or elective cesarean sections at >= 37 and < 39 weeks of gestation completed.
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CMS114 VTE-6 Incidence of potentially preventable VTE
This measure assesses the number of patients diagnosed with confirmed VTE during hospitalization (not present at admission) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date.
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CMS171 SCIP-INF-1 Prophylactic Antibiotic Received within 1 Hour Prior to Surgical Incision
Surgical patients with prophylactic antibiotics initiated within one hour prior to surgical incision. Patients who received Vancomycin or a Fluoroquinolone for prophylactic antibiotics should have the antibiotics initiated within 2 hours prior to surgical incision. Due to the longer infusion time required for Vancomycin or a Fluoroquinolone, it is acceptable to start these antibiotics within 2 hours prior to incision time.
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CMS172 SCIP-INF-2-Prophylactic Antibiotic Selection for Surgical Patients
Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure).
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CMS178 SCIP-INF-9- Urinary catheter removed on Postoperative Day 1 (POD1) or Postoperative Day 2 (POD2) with day of surgery being day zero.
Surgical patients with urinary catheter removed on Postoperative Day 1 or Postoperative Day 2 with day of surgery being day zero.
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CMS185 Healthy Term Newborn
Percent of term singleton livebirths (excluding those with diagnoses originating in the fetal period) who DO NOT have significant complications during birth or the nursery care.
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CMS188 PN-6- Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients
Immunocompetent patients with Community-Acquired Pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines.
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CMS190 VTE-2 Intensive Care Unit (ICU) VTE prophylaxis
This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after the initial admission (or transfer) to the Intensive Care Unit (ICU) or surgery end date for surgeries that start the day of or the day after ICU admission (or transfer).
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Capability Tags
Summary Record Exchange (SRE) Tag
A certified Complete EHR or certified EHR Module listed on the CHPL with the “SRE” tag means that it was certified to three certification criteria that together support interoperable summary care record exchange. More specifically, the two “transitions of care” certification criteria adopted at 45 CFR 170.314(b)(1) and (b)(2), and the clinical information reconciliation certification criterion adopted at 45 CFR 170.314(b)(4).
170.314(b)(1) 170.314(b)(2) 170.314(b)(4)
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2014 CQM Domains
Care Coordination
CMS32 CMS50 CMS102
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Clinical Process/Effectiveness
CMS9 CMS30 CMS31 CMS52 CMS53 CMS60 CMS61 CMS62 CMS64 CMS65 CMS71 CMS72 CMS73 CMS74 CMS75 CMS77 CMS91 CMS100 CMS104 CMS105 CMS109 CMS113 CMS122 CMS123 CMS124 CMS125 CMS126 CMS127 CMS128 CMS130 CMS131 CMS133 CMS134 CMS135 CMS136 CMS137 CMS140 CMS141 CMS142 CMS143 CMS144 CMS145 CMS148 CMS149 CMS158 CMS159 CMS160 CMS161 CMS163 CMS164 CMS165 CMS167 CMS169 CMS182
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Efficient Use of Healthcare Resources
CMS129 CMS146 CMS154 CMS166 CMS172 CMS188
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Patient & Family Engagement
CMS26 CMS55 CMS56 CMS66 CMS90 CMS107 CMS110 CMS111 CMS157
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Patient Safety
CMS68 CMS108 CMS114 CMS132 CMS139 CMS156 CMS171 CMS177 CMS178 CMS179 CMS185 CMS190
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Population/Public Health
CMS2 CMS22 CMS69 CMS82 CMS117 CMS138 CMS147 CMS153 CMS155
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11/21/2014