2014 Massachusetts Standard Quality Measure Set10/29/14

2014 Massachusetts Standard Quality Measure Set 10/29/14 Physician Group/Practice Measures

Data Measure/Tool Measure Set Data Source(s) Already Mandated Name Type Reported Consumer Assessment of Healthcare Providers and CAHPS Survey PE X X Systems (CAHPS) - Clinician & Group Survey Therapeutic monitoring: Annual monitoring for MHQP (Claims & clinical HEDIS P X X patients on records) persistent medications Use of spirometry testing in the assessment and MHQP (Claims & clinical diagnosis of HEDIS P X X records) chronic obstructive pulmonary disease (COPD) Cholesterol management for MHQP (Claims & clinical patients with HEDIS O X X records) cardiovascular conditions Controlling high MHQP (Claims & clinical HEDIS O X blood pressure records) Comprehensive HEDIS Claims & clinical records C X diabetes care Use of appropriate medications for MHQP (Claims & clinical HEDIS P X X people with records) asthma

of 12 2014 Massachusetts Standard Quality Measure Set 10/29/14

Disease modifying anti-rheumatic drug therapy for HEDIS Claims & clinical records P X rheumatoid arthritis Osteoporosis management in HEDIS Claims & clinical records P X women who had fracture Pharmacotherapy of chronic obstructive HEDIS Claims & clinical records P X pulmonary disease (COPD) exacerbation Medication management for HEDIS Claims & clinical records P X people with asthma (MMA) Asthma Medication HEDIS Claims & clinical records P X Ratio CAHPS Health Plan Survey: Children with Chronic HEDIS Survey C X X Conditions Supplement Fall Risk HEDIS Claims & clinical records P X Management Potentially harmful drug-disease HEDIS Claims & clinical records P X interactions in the elderly Avoidance of antibiotic MHQP (Claims & clinical treatment in adults HEDIS P X records) with acute bronchitis Measure/Tool Data Source(s) Measure Data Mandated Name Set Type Already

Reported Use of imaging MHQP (Claims & clinical studies for low HEDIS P X records) back pain Use of high-risk medications in the HEDIS Claims & clinical records P X elderly Care for older adults - medication HEDIS Claims & clinical records P X review Persistence of beta-blocker HEDIS Claims & clinical records P X treatment after a heart attack Glaucoma screening in older HEDIS Claims & clinical records P X adults Urinary Incontinence HEDIS Claims & clinical records P X Management in Older Adults Counseling on Physical Activity in HEDIS Claims & clinical records P X Older Adults Aspirin Use and HEDIS Claims & clinical records P X Discussion Medication reconciliation post- HEDIS Claims & clinical records P X discharge Appropriate treatment for MHQP (Claims & clinical children with HEDIS P X X records) upper respiratory infection Well-child visits in the third, fourth, MHQP (Claims & clinical HEDIS U X X fifth and sixth records) years of life Appropriate HEDIS MHQP (Claims & clinical P X

of 12 2014 Massachusetts Standard Quality Measure Set 10/29/14 testing of children records) with pharyngitis Follow-up care for children MHQP (Claims & clinical HEDIS P X X prescribed ADHD records) medication Adolescent well- MHQP (Claims & clinical HEDIS U X X care visits records) Childhood immunization HEDIS Claims & clinical records P X status Immunizations for HEDIS Claims & clinical records P X adolescents Lead screening in HEDIS Claims & clinical records P X children Weight assessment and counseling for nutrition and physical activity HEDIS Claims & clinical records P X for children/adolescen ts Data Measure/Tool Measure Set Data Source(s) Already Mandated Name Type Reported Children's and adolescents' access HEDIS Claims & clinical records A X to primary care practitioners Human Papillomavirus HEDIS Claims & clinical records P X Vaccine for Female Adolescents Frequency of ongoing prenatal HEDIS Claims & clinical records O X care Prenatal and HEDIS Claims & clinical records O X postpartum care Well-child visits in HEDIS MHQP (Claims & clinical U X X

of 12 2014 Massachusetts Standard Quality Measure Set 10/29/14 the first 15 months records) of life Breast cancer MHQP (Claims & clinical HEDIS P X X screening records) Colorectal cancer MHQP (Claims & clinical HEDIS P X X screening records) Cervical cancer MHQP (Claims & clinical HEDIS P X X screening records) Chlamydia MHQP (Claims & clinical screening in HEDIS P X X records) women Adult BMI HEDIS Claims & clinical records P X Assessment Adults' access to preventive/ambula HEDIS Claims & clinical records A X tory health services Flu shots for older HEDIS Claims & clinical records P X adults Pneumonia vaccination status HEDIS Claims & clinical records P X for older adults Osteoporosis Testing in Older HEDIS Claims & clinical records P X Women Flu Shots for HEDIS Claims & clinical records P X Adults Ages 50-64 Annual dental visit HEDIS Claims & clinical records O X Initiation and engagement of alcohol and other HEDIS Claims & clinical records P X drug dependence treatment Medical Assistance With Smoking and HEDIS Survey P X Tobacco Use Cessation

Measure Data

Measure/Tool Set Already Data Source(s) Type Mandated Name Reported Antidepressant MHQP (Claims & clinical medication HEDIS P X X records) management Follow-up after hospitalization for HEDIS Claims & clinical records P X mental illness Adherence to Antipsychotics for HEDIS Claims & clinical records P X Individuals with Schizophrenia Diabetes Screening for People with Schizophrenia or Bipolar Disorder HEDIS Claims & clinical records P X Who are Using Antipsychotic Medications Diabetes Monitoring for People with HEDIS Claims & clinical records P X Diabetes and Schizophrenia Cardiovascular Monitoring for People with HEDIS Claims & clinical records P X Cardiovascular Disease and Schizophrenia Non- Recommended Cervical Cancer HEDIS Claims & clinical records P X Screening in Adolescent Females Asthma in younger PQI HDD O X adults (PQI 15) Chronic PQI Claims & clinical records O X

of 12 2014 Massachusetts Standard Quality Measure Set 10/29/14 obstructive pulmonary disease (PQI 5) Congestive Heart Failure Admission PQI HDD O X Rate (PQI 8) Diabetes Short- Term Complications PQI Claims & clinical records O X Admission Rate (PQI 1) Low Birth Weight PQI HDD or DPH reporting O X Rate (PQI 9) Screening for Claims & clinical records P Clinical Depression Measure pair: a. Tobacco Use Assessment, b. AMA-PCPI Claims & clinical records P Tobacco Cessation Intervention Unhealthy Alcohol Use: Screening & Claims & clinical records P Brief Counseling Asthma Emergency HDD O Department Visits Depression Clinical records Utilization of the P PHQ-9 Tool Maternal Clinical records Depression P Screening Depression Clinical records screening by 18 P years of age

Hospital Measures

Data NQF Measure Measure/Tool Name Set Data Source(s) Already Mandated # Type Reported Prophylactic antibiotic received within 1-hour prior to surgical incision CMS/Hospital SCIP-Inf 527 P X X (SCIP-Inf-1a) Compare CMS/Hospital Prophylactic antibiotic selection for surgical patients (SCIP-Inf-2a) SCIP-Inf 528 P X X Compare Prophylactic antibiotics discontinued within 24 hours after surgery end CMS/Hospital SCIP-Inf 529 P X X time (SCIP-Inf-3a) Compare Cardiac Surgery Patients With Controlled Postoperative Blood Glucose CMS/Hospital SCIP-Inf 300 P X X (SCIP-Inf-4) Compare Urinary Catheter Removed on Postoperative Day 1 (POD 1) or CMS/Hospital Postoperative Day 2 (POD 2) with day of surgery being day zero (SCIP- SCIP-Inf 453 P X X Compare Inf-9) Surgery Patients with Perioperative Temperature Management (SCIP- CMS/Hospital SCIP-Inf 452 P X X Inf-10) Compare Surgery patients with recommended venous thromboembolism SCIP- CMS/Hospital P X X prophylaxis ordered (SCIP-VTE-1) VTE Compare Surgery patients who received appropriate venous thromboembolism SCIP- CMS/Hospital prophylaxis within 24 hours prior to surgery to 24 hours after surgery 218 P X X VTE Compare (SCIP-VTE-2) Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who SCIP- CMS/Hospital 284 P X X received a Beta-Blocker During the Perioperative Period (SCIP-Card-2) Card Compare Claims & clinical Plan All-Cause Readmission (NCQA) HEDIS 1768 O X records 143 CMS/Hospital Relievers for inpatient asthma (CAC 1) CAC P Compare 144 CMS/Hospital Systemic corticosteroids for inpatient asthma (CAC 2) CAC P Compare Home Management Plan of Care Document Given to Patient/Caregiver CMS/Hospital CAC P (CAC 3) Compare Hospital-Wide All-Cause Unplanned Readmission Measure (Yale/CMS) 1789 HDD O Timely transmission of transition record (CCM 3) CCM Clinical records P CMS/Hospital Detailed Discharge Instructions (HF 1) HF P X X Compare CMS/Hospital Evaluation of Left Ventricular Systolic (LVS) Function (HF 2) HF 135 P X X Compare Measure/Tool Name NQF Data Source(s) Measure Data Mandated Set # Type Already

Reported Initial antibiotic selection for community-acquired pneumonia (CAP) in CMS/Hospital PN 147 P X X immunocompetent patients (PN 6) Compare CMS/Hospital Aspirin prescribed at discharge for AMI (AMI 2) AMI 142 P X X Compare Fibrinolytic therapy received within 30 minutes of hospital arrival CMS/Hospital AMI 164 P X X (AMI 7a) Compare Primary percutaneous coronary intervention (PCI) received within 90 CMS/Hospital AMI 163 P X X minutes of hospital arrival (AMI 8a) Compare CMS/Hospital Statin Prescribed at Discharge (AMI 10) AMI 639 P X X Compare Hospital Consumer Assessment of Healthcare Providers and Systems 166/ CAHPS Survey PE/C X X (HCAHPS) (Includes 13 measures: 10 HCAHPS and CTM-3) 228 Computerized physician order entry standards Leapfrog S X Rate of Babies Electively Delivered Before Full-Term Leapfrog P X Pressure Ulcer Rate (PSI 3) PSI HDD O X Iatrogenic Pneumothorax Rate (PSI 6) PSI 346 HDD O X Central Venous Catheter-related Blood Stream Infection Rate (PSI 7) PSI HDD O X Post-operative Respiratory Failure Rate (PSI 11) PSI 533 HDD O X Post-operative Pulmonary Embolism or Deep Vein Thrombosis PSI 450 HDD O X (PE/DVT) Rate (PSI 12) Accidental Puncture or Laceration Rate (PSI 15) PSI 345 HDD O X Post-operative Hip Fracture Rate (PSI 8) PSI HDD O X Birth Trauma Rate: Injury to Neonates (PSI 17) PSI HDD O X Obstetric Trauma: Vaginal Delivery with Instrument (PSI 18) PSI HDD O X Obstetric Trauma: Vaginal Delivery without Instrument (PSI 19) PSI HDD O X Patients discharged on multiple antipsychotic medications (HBIPS 4) HBIPS 552 Clinical records P Post discharge continuing care plan transmitted to next level of care HBIPS 558 Clinical records P provider upon discharge (HBIPS 7) Post discharge continuing care plan created (HBIPS 6) HBIPS 557 Clinical records P High-risk Newborn Deliveries (PC-03) PC 476 Leapfrog O X Newborn Bilirubin Screening & DVT Prophylaxis in Women Leapfrog P X Undergoing Cesarean Section Incidence of Episiotomy Leapfrog O X Aortic Valve Replacement Leapfrog O X Data NQF Measure Measure/Tool Name Set Data Source(s) Already Mandated # Type Reported

Pancreatic Resection 738 Leapfrog O X Claims & clinical Cesarean Section (PC-02) PC 471 O records Patient Safety Composite (PSI 90) PSI 531 HDD C X CMS/Hospital Pneumonia 30-day mortality rate 468 O X Compare CMS/Hospital Heart failure 30-day mortality rate 229 O X Compare CMS/Hospital AMI 30-day mortality rate 230 O X Compare Hospital-onset methicillin resistant staphylococcus bacteremia aureus CMS Hospital 1716 O X (MRSA) Compare CMS Hospital Central-Line Associated Bloodstream Infection 139 O X Compare CMS Hospital Hospital-onset C. difficile 1717 O X Compare CMS Hospital Catheter-Associated Urinary Tract Infections 138 O X Compare CMS Hospital SSI Surgical Site Infection: SSI colon, SSI-abdominal hysterectomy 753 O X Compare

Post- Acute Measures

Data NQF Measure Measure/Tool Name Set Data Source(s) Already Mandated # Type Reported CMS/Home Acute care hospitalization (risk-adjusted) OASIS 171 O X Health Compare CMS/Home Emergency Department Care without Hospitalization (risk-adjusted) OASIS 173 O X Health Compare CMS/ Home Timely Initiation of Care OASIS 526 P X Health Compare Percent of Residents with Pressure Ulcers That Are New or Worsened CMS/Nursing 678 O X (Short-Stay) Home Compare CMS/Nursing Percent of High Risk Residents with Pressure Ulcers (Long Stay) 679 O X Home Compare Percent of Residents Who Self-Report Moderate to Severe Pain (Short- CMS/Nursing 676 O X Stay) Home Compare

Percent of Residents Who Self-Report Moderate to Severe Pain (Long- CMS/Nursing 677 O X Stay) Home Compare Claims & clinical Proportion admitted to hospice for less than 3 days 216 P records Advance Care Plan 326 Claims P Palliative and End of Life Care: Dyspnea Screening & Management Clinical records P Pain Screening* HIS 1634 CMS P 2016 Pain Assessment* HIS 1637 CMS P 2016 Dyspnea Screening* HIS 1639 CMS P 2016 Dyspnea Treatment* HIS 1638 CMS P 2016 Beliefs/Values Addressed* HIS 1647 CMS P 2016 Hospice and Palliative Care – Treatment Preferences* HIS 1641 CMS P 2016 *May apply to care delivered in acute and non-acute settings Added to set in 2014

Measure Types P Process O Outcome C Composite U Use of Services A Access S Structural PE Patient Engagement/Experience

Measure Sets HEDIS Healthcare Effectiveness Data and Information Set PQI Prevention Quality Indicators HF Heart Failure PSI Patient Safety Indicators CAC Children’s Asthma Care AMI Acute Myocardial Infarction SCIP Surgical Care Improvement Project The Consumer Assessment of Healthcare Providers and CAHPS Systems OASIS Outcome and Assessment Information Set AMA-PCPI AMA’s Physician Consortium for Performance Improvement

HBIPS Hospital-based Inpatient Psychiatric Services HIS Hospice Item Set PC Perinatal Care