eCQM Title | ZZ_AnnualWellnessAssessmentMeasure_AllOrNothing |
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eCQM Identifier (Measure Authoring Tool) | eCQM Version number | 0.0.001 | |||||||||||||||||||
NQF Number | None | GUID | 20619ccd-4d5a-45ce-95dc-d1052d890dab | ||||||||||||||||||
Measurement Period | January 1, 20XX through December 31, 20XX | ||||||||||||||||||||
Measure Steward | National Committee for Quality Assurance | ||||||||||||||||||||
Measure Developer | Telligen | ||||||||||||||||||||
Endorsed By | None | ||||||||||||||||||||
Description | |||||||||||||||||||||
Copyright | |||||||||||||||||||||
Disclaimer | |||||||||||||||||||||
Measure Scoring | Proportion | ||||||||||||||||||||
Measure Type | Composite | ||||||||||||||||||||
Component Measure |
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Stratification | |||||||||||||||||||||
Risk Adjustment | |||||||||||||||||||||
Rate Aggregation | |||||||||||||||||||||
Rationale | |||||||||||||||||||||
Clinical Recommendation Statement | |||||||||||||||||||||
Improvement Notation | |||||||||||||||||||||
Reference | |||||||||||||||||||||
Definition | |||||||||||||||||||||
Guidance | |||||||||||||||||||||
Transmission Format | |||||||||||||||||||||
Initial Population | |||||||||||||||||||||
Measure Population | |||||||||||||||||||||
Measure Population Exclusions | |||||||||||||||||||||
Measure Observations | |||||||||||||||||||||
Supplemental Data Elements |
ScreeningForAlcoholMisuse."Initial Population" or HypertensionAssessment."Initial Population" or ScreeningForBreastCancer."Initial Population" or ScreeningForColorectalCancer."Initial Population" or ScreeningForDepression."Initial Population"
["Patient Characteristic Birthdate"] P where ( ScreeningForAlcoholMisuse."Denominator" and not ScreeningForAlcoholMisuse."Denominator Exclusions" ) or HypertensionAssessment."Denominator" or ( ScreeningForBreastCancer."Denominator" and not ScreeningForBreastCancer."Denominator Exclusions" ) or ( ScreeningForColorectalCancer."Denominator" and not ScreeningForColorectalCancer."Denominator Exclusions" ) or ( ScreeningForDepression."Denominator" and not ScreeningForDepression."Denominator Exclusions" )
Average ( "Numerator Score" / "Denominator Score" )
["Encounter, Performed": "Annual Wellness Visit"] AWV with ["Patient Characteristic Birthdate": "Birthdate"] BirthDate such that "CalendarAgeInYearsAt"(BirthDate.birthDatetime, start of "Measurement Period")>= 65 and AWV.relevantPeriod during "Measurement Period"
if ScreeningForAlcoholMisuse."Initial Population" and ( ScreeningForAlcoholMisuse."Denominator" and not ScreeningForAlcoholMisuse."Denominator Exclusions" ) then 1 else 0 + if HypertensionAssessment."Initial Population" and HypertensionAssessment."Denominator" then 1 else 0 + if ScreeningForBreastCancer."Initial Population" and ( ScreeningForBreastCancer."Denominator" and not ScreeningForBreastCancer."Denominator Exclusions" ) then 1 else 0 + if ScreeningForColorectalCancer."Initial Population" and ( ScreeningForColorectalCancer."Denominator" and not ScreeningForColorectalCancer."Denominator Exclusions" ) then 1 else 0 + if ScreeningForDepression."Initial Population" and ( ScreeningForDepression."Denominator" and not ScreeningForDepression."Denominator Exclusions" ) then 1 else 0
["Patient Characteristic Birthdate"] P where ScreeningForAlcoholMisuse."Initial Population" or HypertensionAssessment."Initial Population" or ScreeningForBreastCancer."Initial Population" or ScreeningForColorectalCancer."Initial Population" or ScreeningForDepression."Initial Population"
["Patient Characteristic Birthdate"] P where ( ScreeningForAlcoholMisuse."Denominator" and not ScreeningForAlcoholMisuse."Denominator Exclusions" ) or HypertensionAssessment."Denominator" or ( ScreeningForBreastCancer."Denominator" and not ScreeningForBreastCancer."Denominator Exclusions" ) or ( ScreeningForColorectalCancer."Denominator" and not ScreeningForColorectalCancer."Denominator Exclusions" ) or ( ScreeningForDepression."Denominator" and not ScreeningForDepression."Denominator Exclusions" )
if ScreeningForAlcoholMisuse."Initial Population" and ( ScreeningForAlcoholMisuse."Denominator" and not ScreeningForAlcoholMisuse."Denominator Exclusions" ) and ScreeningForAlcoholMisuse."Numerator" then 1 else 0 + if HypertensionAssessment."Initial Population" and HypertensionAssessment."Denominator" and HypertensionAssessment."Numerator" then 1 else 0 + if ScreeningForBreastCancer."Initial Population" and ( ScreeningForBreastCancer."Denominator" and not ScreeningForBreastCancer."Denominator Exclusions" ) and ScreeningForBreastCancer."Numerator" then 1 else 0 + if ScreeningForColorectalCancer."Initial Population" and ( ScreeningForColorectalCancer."Denominator" and not ScreeningForColorectalCancer."Denominator Exclusions" ) and ScreeningForColorectalCancer."Numerator" then 1 else 0 + if ScreeningForDepression."Initial Population" and ( ScreeningForDepression."Denominator" and not ScreeningForDepression."Denominator Exclusions" ) and ScreeningForDepression."Numerator" then 1 else 0
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
true
exists ( ["Diagnosis": "Alcohol abuse or dependence"] Dx with AWV."Annual Wellness Encounters" AWV such that Dx.prevalencePeriod overlaps before AWV.relevantPeriod )
exists ( AWV."Annual Wellness Encounters" )
exists ( ["Assessment, Performed": "AUDIT C Total Score (in points)"] AuditC with AWV."Annual Wellness Encounters" AWV such that AuditC.authorDatetime 12 months or less on or before end of AWV.relevantPeriod ) or exists ( ( ( ["Assessment, Performed": "Frequency of Drinking in the Past Year"] DrinkingFrequency where DrinkingFrequency.result in "Never Response" ) union ( ["Assessment, Performed": "Alcohol Abuse Screening"] AlcoholAbuse where AlcoholAbuse.result in "Current Non Drinker of Alcohol" ) ) Assessment with AWV."Annual Wellness Encounters" AWV such that Assessment.authorDatetime 12 months or less on or before end of AWV.relevantPeriod ) //TODO: /*OR: AND: Union of: "Risk Category Assessment: Frequency of Drinking in the Past Year (result: Times Per Week Or Month Response)" "Risk Category Assessment: Alcohol Abuse Screening (result: Current Drinker of Alcohol)" <= 12 month(s) ends before end of "Occurrence A of Encounter, Performed: Annual Wellness Visit" AND: Union of: "Risk Category Assessment: Frequency of Four or More Drinks on One Occasion in Past Year (result: Heavy Drinking Days in Past Year Response)" "Risk Category Assessment: Frequency of Four or More Drinks on One Occasion in Past Year (result >= 0 )" <= 12 month(s) ends before end of "Occurrence A of Encounter, Performed: Annual Wellness Visit"*/ or exists ( ( ( ["Assessment, Performed": "Frequency of Drinking in the Past Year"] DrinkingFrequency where DrinkingFrequency.result in "Times Per Week Or Month Response" ) union ( ["Assessment, Performed": "Alcohol Abuse Screening"] AlcoholAbuse where AlcoholAbuse.result in "Current Drinker of Alcohol" ) ) Assessment with AWV."Annual Wellness Encounters" AWV such that Assessment.authorDatetime 12 months or less on or before end of AWV.relevantPeriod )
"Initial Population"
exists (AWV."Annual Wellness Encounters")
exists ( ["Physical Exam, Performed"] Exam with AWV."Annual Wellness Encounters" WellnessEncounter such that Exam.relevantPeriod during "Measurement Period" where exists ( Exam.components Systolic where Systolic.code in "Systolic Blood Pressure" and Systolic.result is not null ) and exists ( Exam.components Diastolic where Diastolic.code in "Diastolic Blood Pressure" and Diastolic.result is not null ) )
exists ( ["Patient Characteristic Birthdate": "Birthdate"] BirthDate where Global."CalendarAgeInYearsAt"(BirthDate.birthDatetime, start of "Measurement Period")< 75 and exists ( ["Patient Characteristic Sex": "Female"] ) )
exists ( ["Procedure, Performed": "Bilateral Mastectomy"] Bilateral where Bilateral.relevantPeriod ends on or before end of "Measurement Period" ) or Count(["Procedure, Performed": "Unilateral Mastectomy"] Unilateral where Unilateral.relevantPeriod ends on or before end of "Measurement Period" )= 2
exists ( AWV."Annual Wellness Encounters" )
exists ( ["Diagnostic Study, Performed": "Mammography"] Mammogram where Mammogram.result is not null and Mammogram.relevantPeriod ends 26 months or less on or before end of "Measurement Period" )
exists ( ["Patient Characteristic Birthdate": "Birthdate"] BirthDate where Global."CalendarAgeInYearsAt"(BirthDate.birthDatetime, start of "Measurement Period")< 75 )
exists ( ["Procedure, Performed": "Total Colectomy"] Colectomy where Colectomy.relevantPeriod ends before end of "Measurement Period" ) or exists ( ["Diagnosis": "Malignant Neoplasm of Colon"] Neoplasm where Neoplasm.prevalencePeriod starts before end of "Measurement Period" )
exists ( AWV."Annual Wellness Encounters" )
exists ( ["Procedure, Performed": "Colonoscopy"] Colonoscopy where Colonoscopy.relevantPeriod ends 9 years or less on or before end of "Measurement Period" ) or exists ( ["Laboratory Test, Performed": "Fecal Occult Blood Test (FOBT)"] FOBT where FOBT.authorDatetime during "Measurement Period" and FOBT.result is not null ) or exists ( ["Procedure, Performed": "Flexible Sigmoidoscopy"] Sigmoidoscopy where Sigmoidoscopy.relevantPeriod ends 4 years or less on or before end of "Measurement Period" )
"Initial Population"
exists( ["Diagnosis": "Depression or Bipolar Disorder"] Bipolar with AWV."Annual Wellness Encounters" AWV such that Bipolar.prevalencePeriod overlaps before AWV.relevantPeriod )
exists ( AWV."Annual Wellness Encounters" )
exists ( ["Assessment, Performed": "PHQ 2 Total Score (in points)"] PHQ_2 with AWV."Annual Wellness Encounters" AWV such that PHQ_2.authorDatetime 12 months or less on or before end of AWV.relevantPeriod )
years between ToDate(BirthDateTime)and ToDate(AsOf)
DateTime(year from Value, month from Value, day from Value, 0, 0, 0, 0, timezone from Value)
years between ToDate(BirthDateTime)and ToDate(AsOf)
DateTime(year from Value, month from Value, day from Value, 0, 0, 0, 0, timezone from Value)
"Numerator Score" / "Denominator Score"
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
Measure Set |