iPatientCare Inpatient EHR


2014 (2.0)
Last Modified 07/17/2014

Vendor

Versions

Certification Edition

CHPL Certification ID

iPatientCare, Inc. 2014 (2.0) 2014 140180R00

Certifying Body

Classification

Practice Type

ICSA Labs Complete EHR Inpatient

Required Software

iPatientCare EIA (Enterprise Integration Adaptors), iPatientCare HISP, MedlinePlus Connect, Meinberg NTP Time Server Monitor, iPatientCare PHR

Certification Criteria

  • 170.314(a)(1) Met
    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.
  • 170.314(a)(2) Met
    170.314(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.
  • 170.314(a)(3) Met
    170.314(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.
  • 170.314(a)(4) Met
    170.314(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.
  • 170.314(a)(5) Met
    170.314(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).
  • 170.314(a)(6) Met
    170.314(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.
  • 170.314(a)(7) Met
    170.314(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.
  • 170.314(a)(8) Met
    170.314(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
  • 170.314(a)(9) Met
    170.314(a)(9)  ELECTRONIC NOTES
    Electronic notes. Enable a user to electronically record, change, access, and search electronic notes.
  • 170.314(a)(10) Met
    170.314(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.
  • 170.314(a)(11) Met
    170.314(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).
  • 170.314(a)(12) Met
    170.314(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.
  • 170.314(a)(13) Met
    170.314(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).
  • 170.314(a)(14) Met
    170.314(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.
  • 170.314(a)(15) Met
    170.314(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.
  • 170.314(a)(16) Met
    170.314(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.
  • 170.314(a)(17) Met
    170.314(a)(17)  ADVANCE DIRECTIVES
    Advance directives. Enable a user to electronically record whether a patient has an advance directive.
  • 170.314(a)(18) Not Met
    170.314(a)(18)  COMPUTERIZED PROVIDER ORDER ENTRY - MEDICATIONS
  • 170.314(a)(19) Not Met
    170.314(a)(19)  COMPUTERIZED PROVIDER ORDER ENTRY - LABORATORY
  • 170.314(a)(20) Not Met
    170.314(a)(20)  COMPUTERIZED PROVIDER ORDER ENTRY - DIAGNOSTIC IMAGING
  • 170.314(b)(1) Met
    170.314(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).
  • 170.314(b)(2) Met
    170.314(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).
  • 170.314(b)(3) Met
    170.314(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).
  • 170.314(b)(4) Met
    170.314(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.
  • 170.314(b)(5) Met
    170.314(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.
  • 170.314(b)(6) Met
    170.314(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).
  • 170.314(b)(7) Met
    170.314(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.
  • 170.314(b)(8) Not Met
    170.314(b)(8)  TRANSITIONS OF CARE
  • 170.314(b)(9) Not Met
    170.314(b)(9)  CLINICAL INFORMATION RECONCILIATION AND INCORPORATION
  • 170.314(c)(1) Met
    170.314(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.
  • 170.314(c)(2) Met
    170.314(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.
  • 170.314(c)(3) Met
    170.314(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.
  • 170.314(d)(1) Met
    170.314(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.
  • 170.314(d)(2) Met
    170.314(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.
  • 170.314(d)(3) Met
    170.314(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).
  • 170.314(d)(4) Met
    170.314(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.
  • 170.314(d)(5) Met
    170.314(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.
  • 170.314(d)(6) Met
    170.314(d)(6)  EMERGENCY ACCESS
    Emergency access. Permit an identified set of users to access electronic health information during an emergency.
  • 170.314(d)(7) Met
    170.314(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.
  • 170.314(d)(8) Met
    170.314(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.
  • 170.314(d)(9) Met
    170.314(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).
  • 170.314(e)(1) Met
    170.314(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
  • 170.314(e)(2) Not Met
    170.314(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.
  • 170.314(e)(3) Not Met
    170.314(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).
  • 170.314(f)(1) Met
    170.314(f)(1)  IMMUNIZATION INFORMATION
    Immunization information. Enable a user to electronically record, change, and access immunization information.
  • 170.314(f)(2) Met
    170.314(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).
  • 170.314(f)(3) Met
    170.314(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).
  • 170.314(f)(4) Met
    170.314(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).
  • 170.314(f)(5) Not Met
    170.314(f)(5)  CANCER CASE INFORMATION
    Cancer case information. Enable a user to electronically record, change, and access cancer case information.
  • 170.314(f)(6) Not Met
    170.314(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).
  • 170.314(f)(7) Not Met
    170.314(f)(7)  TRANSMISSION TO PUBLIC HEALTH AGENCIES - SYNDROMIC SURVEILLANCE
  • 170.314(g)(1) Not Met
    170.314(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.
  • 170.314(g)(2) Met
    170.314(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.
  • 170.314(g)(3) Met
    170.314(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).
  • 170.314(g)(4) Met
    170.314(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.
  • 170.314(h)(1) Not Met
    170.314(h)(1)  APPLICABILITY STATEMENT FOR SECURE HEALTH TRANSPORT
  • 170.314(h)(2) Not Met
    170.314(h)(2)  APPLICABILITY STATEMENT FOR SECURE HEALTH TRANSPORT AND XDR/XDM FOR DIRECT MESSAGING
  • 170.314(h)(3) Not Met
    170.314(h)(3)  SOAP TRANSPORT AND SECURITY SPECIFICATION AND XDR/XDM FOR DIRECT MESSAGING

Clinical Quality Measures

  • CMS2 Not Met
    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.
  • CMS9 Not Met
    CMS9  EXCLUSIVE BREAST MILK FEEDING
    Exclusive breast milk feeding during the newborn's entire hospitalization.
  • CMS22 Not Met
    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
  • CMS26 Not Met
    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.
  • CMS30 Not Met
    CMS30  AMI-10 STATIN PRESCRIBED AT DISCHARGE
    Acute Myocardial Infarction (AMI) patients who are prescribed a statin at hospital discharge.
  • CMS31 Not Met
    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.
  • CMS32 Met
    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.
  • CMS50 Not Met
    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.
  • CMS52 Not Met
    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
  • CMS53 Not Met
    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.
  • CMS55 Met
    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.
  • CMS56 Not Met
    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.
  • CMS60 Not Met
    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.
  • CMS61 Not Met
    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.
  • CMS62 Not Met
    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
  • CMS64 Not Met
    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.
  • CMS65 Not Met
    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.
  • CMS66 Not Met
    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.
  • CMS68 Not Met
    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.
  • CMS69 Not Met
    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
  • CMS71 Met
    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.
  • CMS72 Met
    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.
  • CMS73 Met
    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.
  • CMS74 Not Met
    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.
  • CMS75 Not Met
    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.
  • CMS77 Not Met
    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.
  • CMS82 Not Met
    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.
  • CMS90 Not Met
    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
  • CMS91 Met
    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.
  • CMS100 Not Met
    CMS100  AMI-2-ASPIRIN PRESCRIBED AT DISCHARGE FOR AMI
    Acute myocardial infarction (AMI) patients who are prescribed aspirin at hospital discharge.
  • CMS102 Met
    CMS102  STROKE-10 ISCHEMIC OR HEMORRHAGIC STROKE – ASSESSED FOR REHABILITATION
    Ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services.
  • CMS104 Met
    CMS104  STROKE-2 ISCHEMIC STROKE – DISCHARGED ON ANTI-THROMBOTIC THERAPY
    Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge.
  • CMS105 Met
    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.
  • CMS107 Met
    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.
  • CMS108 Met
    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.
  • CMS109 Met
    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.
  • CMS110 Met
    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.
  • CMS111 Met
    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.
  • CMS113 Not Met
    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.
  • CMS114 Met
    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.
  • CMS117 Not Met
    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.
  • CMS122 Not Met
    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.
  • CMS123 Not Met
    CMS123  DIABETES: FOOT EXAM
    Percentage of patients aged 18-75 years of age with diabetes who had a foot exam during the measurement period.
  • CMS124 Not Met
    CMS124  CERVICAL CANCER SCREENING
    Percentage of women 21-64 years of age, who received one or more Pap tests to screen for cervical cancer.
  • CMS125 Not Met
    CMS125  BREAST CANCER SCREENING
    Percentage of women 40-69 years of age who had a mammogram to screen for breast cancer.
  • CMS126 Not Met
    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.
  • CMS127 Not Met
    CMS127  PNEUMONIA VACCINATION STATUS FOR OLDER ADULTS
    Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.
  • CMS128 Not Met
    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).
  • CMS129 Not Met
    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
  • CMS130 Not Met
    CMS130  COLORECTAL CANCER SCREENING
    Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer.
  • CMS131 Not Met
    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
  • CMS132 Not Met
    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.
  • CMS133 Not Met
    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.
  • CMS134 Not Met
    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.
  • CMS135 Not Met
    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
  • CMS136 Not Met
    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.
  • CMS137 Not Met
    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.
  • CMS138 Not Met
    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
  • CMS139 Not Met
    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.
  • CMS140 Not Met
    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
  • CMS141 Not Met
    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
  • CMS142 Not Met
    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
  • CMS143 Not Met
    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
  • CMS144 Not Met
    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
  • CMS145 Not Met
    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
  • CMS146 Not Met
    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.
  • CMS147 Not Met
    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
  • CMS148 Not Met
    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
  • CMS149 Not Met
    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.
  • CMS153 Not Met
    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.
  • CMS154 Not Met
    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.
  • CMS155 Not Met
    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
  • CMS156 Not Met
    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.
  • CMS157 Not Met
    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
  • CMS158 Not Met
    CMS158  PREGNANT WOMEN THAT HAD HBSAG TESTING
    This measure identifies pregnant women who had a HBsAg (hepatitis B) test during their pregnancy.
  • CMS159 Not Met
    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.
  • CMS160 Not Met
    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.
  • CMS161 Not Met
    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.
  • CMS163 Not Met
    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.
  • CMS164 Not Met
    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.
  • CMS165 Not Met
    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.
  • CMS166 Not Met
    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.
  • CMS167 Not Met
    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
  • CMS169 Not Met
    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.
  • CMS171 Not Met
    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.
  • CMS172 Not Met
    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).
  • CMS177 Not Met
    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.
  • CMS178 Not Met
    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.
  • CMS179 Not Met
    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.
  • CMS182 Not Met
    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).
  • CMS185 Not Met
    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.
  • CMS188 Not Met
    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.
  • CMS190 Met
    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).