Clinical Quality Measures
Shannon Earhart, RRT
Sr. Analyst AHIS

Providers must report to CMS or their state
◦ At least six Clinical Quality Measures
 Including 3 Core Measures
 3 Additional Measures

The percentage of patients aged 18 years or older
and who have had their BMI calculated in the past
six months or during the current encounter. If the
most recent BMI is outside normal parameters a follow-up
plan must be documented

Patients with an active diagnosis of pregnancy are
excluded

Patients 18-64- if BMI is 18.5kg/m2 -25kg/m2 the
measure is satisfied. IF BMI is above or below this
range, there must be documentation of a care plan or
consult.

Patients 65 or older- If BMI is 22kg/m2 -30kg/m2
the measure is satisfied. If BMI is above or below this
range, there must documentation of a care plan or consult

Documentation under Preventative Medicine, MU
Objectives category, Provider to Provider or Care
Goal follow-up

The percentage of patients 18 years or older that
have been asked about their tobacco use at least once
in the past two years

Providers must report the percentage of patients
aged 18 years or older that have been identified as
tobacco users within the past two years who have
received tobacco cessation intervention

Complete tobacco use SmartForm

A tobacco cessation intervention- has been
documented within the past two years *Preventative
Medicine, MU Objectives, Smoking

A smoking cessation agent medication has been
ordered or is active within the past two years

The percentage of patients 18 years or older with an
active hypertension diagnosis who have had their
blood pressure recorded in at least two outpatient or
nursing facility encounters.

Measure is satisfied if patients with hypertension
diagnosis have B/P documented in the encounter

Substitute one where Core measure
denominator is 0

The percentage of patients between the ages of 2 and
17 years
◦ who have had an outpatient visit with their PCP or OB/GYN and
◦ who have evidence of BMI percentile documentation, counseling
for nutrition and counseling for physical activity during the
measurement year
Satisfying measure:


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Preventative Medicine-MU objectives category
To document counseling of BMI-chose either Care
Goal follow up plan or provider to provider
To document nutrition counseling and physical
activity counseling- chose communication to
patient


Providers must report the percentage of
patients aged 50 years old or older who have
received an Influenza Immunization during
the flu season( September-February)
Must chose immunization that has a valid CPT
code associated

The percentage of children 2 years of age who have
had the following vaccinations by their second birthday
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4 Diphtheria, tetanus and DTap
3 Polio, one MMR
2 HiB
3 Hep B
1 VZV
4 PCV
2 Hep A
2 or 3 Rotavirus
2 Influenza

Patients are included in the denominator is
>/= to 1 years of age and < 2 yrs of age

Any patient with an allergy or diagnosis
contraindicating the immunization is excluded

Must chose immunization with a valid CPT code
associated

St. Mary’s Health administration made decision on
which three additional measures would be reported

This is for continuity of attestation

The percentage of patients between the ages of 18 and 75
with an active diabetes (Type I or II) diagnosis who have a
blood pressure less than 140/90 mmHg

Patients are included in denominator age 17-74 to capture
all patients who will reach age 18-75 during reporting
period
◦ A medication indicative of diabetes refilled, ordered or
listed as active
◦ Active diabetes diagnosis within 2 years of reporting
period

A-The percentage of patients between 18 and 75
with an active diabetes( type I or II) who have an
LDL result recorded

B-The percentage of patients between 18 and 75
with an active diabetes( type I or II) who have an
LDL result less than 100mg/dL recorded

Patients are included in denominator ages 17-74 to
capture all patients who will reach age 18-75 during
reporting period
◦ A medication indicative of diabetes refilled, ordered or
listed as active
◦ Active diabetes diagnosis within 2 years of reporting period

Clinician must order and result Low Density
LipoProtein –Lipid Panel
◦ (LDL) if first result is >100mg/dL then a follow-up
result recorded < 100mg/dL

A Diagnosis of Polycystic ovaries, Gestational
diabetes or steroid induced diabetes will
exclude the patient

The percentage of patients between ages 18-75
with an active diabetes (type I or II) diagnosis who
have a HbA1c greater than 9.0%

Patients are included in denominator age 17-74 to capture all
pts. Who will reach age 18-75 during reporting period
◦ A medication indicative of diabetes refilled, ordered or listed as
active
◦ Active diabetes diagnosis within 2 years of reporting period

Patients in the denominator are included in this
numerator if a HbA1c > 9.0% is recorded

A Diagnosis of Polycystic ovaries, Gestational diabetes or
steroid induced diabetes within two years before or
simultaneous to the reporting period will exclude the
patient

Implement one clinical decision support rule relevant to
specialty or high clinical priority along with the ability to
track compliance of that rule

Provider may wish to enable CDSS in right chart panel for
quick review File-settings-my settings-show hide

St. Mary’s Administration made decision on which CDSS
measure would be reported

This is for continuity of attestation

Number of patients who have had smoking status
identified or updated at least once in the last 12
months up to and including the last day of the
reporting period

Tobacco SmartForm

Physician Quality Reporting Initiative- May also be
called Physician Quality Reporting System(PQRS)

The PQRI is enabled to prompt the G-Code

The G-Code is the reporting tool for Medicare

PQRI-125 eprescribing
Meaningful Use Class 3 will be covering the 10 Menu
Objectives
Questions?
AHIS Help Desk 812-485-5600