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QCDR/PQRS

Effortless PQRS Reporting

OBERD is a Qualified Clinical Data Registry (QCDR) and can be used for PQRS reporting direct to CMS. OBERD has defined a unique set of orthopaedic measures that assist in PQRS reporting for those specialties. For OBERD clients, this data is collected effortlessly in the background as part of the normal workflow. 

QCDR/PQRS

Meet and report CMS measures effortlessly as part of daily workflows

OBERD collects both patient outcomes and clinical data throughout an entire episode of care, offering unparalleled capability for setting up purpose-driven registries. It is as simple as like-minded physicians agreeing on particular data elements, agreeing to pool their data, and letting OBERD do the rest. OBERD itself has established a Qualified Clinical Data Registry, to submit up to 41 measures to CMS on behalf of our clients.

Contact us to learn more about OBERD QCDR/PQRS solutions 

OBERD QCDR SUPPORTED MEASURES

All of the measures below qualify for PQRS credit. Those labeled “Non-PQRS” were developed by OBERD QCDR and approved by CMS for use in the 2016 PQRS reporting program.

  • NON-PQRS MEASURES

    All of the measures below qualify for PQRS credit. Those labeled “Non-PQRS” were developed by OBERD QCDR and approved by CMS for use in the 2016 PQRS reporting program.

     

    OBERD 1: Back Pain: Mental Health Assessment

    TYPE: Process

    QUALITY DOMAIN: Communication and Care Coordination

    DESCRIPTION: The percentage of patients at least 18 years of age and younger than 80 with a diagnosis of back pain for whom documentation of a mental health assessment is present in the OBERD QCDR prior to intervention or when pain lasts more than 6 weeks.

    DENOMINATOR: Back pain patients at least 18 years of age and younger than 80 who meet either of the following criteria:

    • Evidence of back surgery or epidural steroid injection
    • More than six weeks pain duration

    NUMERATOR: The number of patients with at least one mental health assessment during the eligible episode

    RATIONALE: Pain is the leading symptom with which patients present at spine clinics, and chronic pain is a concomitant of depression. Quality of care will benefit if this linkage is explicitly addressed.

     

    OBERD 2: Back Pain: Patient Reassessment

    TYPE: Process

    QUALITY DOMAIN: Communication and Care Coordination

    DESCRIPTION: Percentage of patients at least 18 years of age and younger than 80 with back pain with documentation that the physician conducted reassessment of both of the following within four to six weeks of their initial back pain visit or of a surgical procedure date:

    • Pain
    • Functional status

    DENOMINATOR: The total patient sample for patients at least 18 years of age and younger than 80

    NUMERATOR:

    • Pain Reassessment: The number of patients with documentation of reassessment of pain within four to six weeks of their initial back pain visit or of a surgical procedure date
    • Functional Status Reassessment: The number of patients with documentation of reassessment of functional status within four to six weeks of their initial back pain visit or of a surgical procedure date

    RATIONALE: Pain is the leading symptom with which patients present at spine clinics. Pain reassessment is necessary if conservative treatment tried first, and surgery without pain relief is a low-quality service.

     

    OBERD 3: Back Pain: Shared Decision Making

    TYPE: Process

    QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

    DESCRIPTION: Percentage of patients at least 18 years of age and younger than 80 with back pain with whom a physician or other clinician reviewed the range of treatment options (including alternatives to surgery) prior to a procedure. To demonstrate shared decision-making, there must be documentation of audio-visual educational material or a discussion between the physician and patient that includes all of the following:

    • Treatment choices, including alternatives to surgery
    • Risks and benefits
    • Evidence of effectiveness

    DENOMINATOR: Patients at least 18 years of age and younger than 80 who had surgery for back pain

    NUMERATOR: The number of patients who had surgery, with documentation of audio-visual educational material or a discussion between the physician and the patient prior to surgery, which includes alternatives to surgery, risks and benefits and evidence of effectiveness

    EXCLUSIONS/EXCEPTIONS: This measure is applicable only for physicians who perform surgery.

    RATIONALE: This is the minimum requirement for patient centered care.

     

    OBERD 4: Pain Assessment and Follow-Up

    TYPE: Process

    QUALITY DOMAIN: Communication and Care Coordination

    DESCRIPTION: Percentage of patients aged 18 years and older with documentation of a pain assessment through discussion with the patient including the use of a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present.

    DENOMINATOR: Patients 18 years of age and older on the date of the encounter

    NUMERATOR: Patient’s pain assessment is documented through discussion with the patient including the use of a standardized tool(s) AND a follow-up plan is documented when pain is present

    EXCLUSIONS/EXCEPTIONS:

    • Severe mental and/or physical incapacity where the person is unable to express himself/herself in a manner understood by others. For example, cases where pain cannot be accurately assessed through use of nationally recognized standardized pain assessment tools.
    • Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status

    RATIONALE: Pain is the leading symptom with which patients present at spine clinics. It is well established that pain can be measured on numerical scales, and this simple monitoring device should not be omitted.

     

    OBERD 5: Back Pain: Surgical Timing

    TYPE: Process

    QUALITY DOMAIN: Efficiency and Cost Reduction

    DESCRIPTION: Percentage of patients at least 18 years of age and younger than 80 with a back pain episode of 28 days or more without documentation of red flags who had surgery within the first six weeks of back pain onset (overuse measure, lower performance is better).

    DENOMINATOR: Patients at least 18 years of age and younger than 80 with a back pain episode of 28 days or more who have had back surgery

    NUMERATOR: The number of patients with a surgical intervention to treat back pain within the first six weeks of pain

    EXCLUSIONS/EXCEPTIONS: This measure is applicable only for physicians who perform surgery.

    RATIONALE: Conservative treatment, which suggests avoiding a rush to surgery, must be balanced with patient wishes and degree of suffering. It is valuable for a provider to track his timing versus common standards.

     

    OBERD 6: Orthopedic Pain: Mental Health Assessment

    TYPE: Process

    QUALITY DOMAIN: Communication and Care Coordination

    DESCRIPTION: Percentage of patients of age 18-80 presenting with pain from an orthopedic condition often treated with surgery who received a mental health assessment.

    DENOMINATOR: Number of patients of age 18-80 presenting with pain from an orthopedic condition often treated with surgery

    NUMERATOR: Number of patients of age 18-80 presenting with pain from an orthopedic condition often treated with surgery who received a mental health assessment prior to surgery

    RATIONALE: This is a straightforward generalization of NQF-316 from back conditions to other orthopedic conditions.

     

    OBERD 7: Orthopedic Pain: Patient Reassessment

    TYPE: Process

    QUALITY DOMAIN: Communication and Care Coordination

    DESCRIPTION: Percentage of patients at least 18 years of age and younger than 80 with orthopedic pain with documentation that the physician conducted reassessment of both of the following within four to six weeks of their initial orthopedic visit or orthopedic surgical procedure date:

    • Pain
    • Functional status

    DENOMINATOR: The total patient sample for patients at least 18 years of age and younger than 80 presenting with orthopedic pain

    NUMERATOR:

    • Pain Reassessment: The number of patients with documentation of reassessment of pain within four to six weeks of their initial orthopedic visit or of a surgical procedure date
    • Functional Status Reassessment: The number of patients with documentation of reassessment of functional status within four to six weeks of their initial orthopedic visit or of a surgical procedure date

    RATIONALE: This is a straightforward generalization of NQF-306 from back conditions to other orthopedic conditions.

     

    OBERD 8: Orthopedic Pain: Shared Decision Making

    TYPE: Process

    QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

    DESCRIPTION: Percentage of patients at least 18 years of age and younger than 80 with orthopedic pain with whom a physician or other clinician reviewed the range of treatment options (including alternatives to surgery) prior to a procedure. To demonstrate shared decision-making, there must be documentation of a discussion between the physician and the patient that includes all of the following:

    • Treatment choices, including alternatives to surgery
    • Risks and benefits
    • Evidence of effectiveness

    DENOMINATOR: Patients at least 18 years of age and younger than 80 who had orthopedic surgery

    NUMERATOR: The number of patients who had orthopedic surgery, with documentation that a clinician and the patient discussed treatment options prior to surgery, including alternatives to surgery, risks and benefits and evidence of effectiveness

    EXCLUSIONS/EXCEPTIONS: This measure is applicable only for physicians who perform surgery.

    RATIONALE: This is a straightforward generalization of NQF-420 from back conditions to other orthopedic conditions.

     

    OBERD 9: Orthopedic Pain: Assessment and follow-up

    TYPE: Process

    QUALITY DOMAIN: Communication and Care Coordination

    DESCRIPTION: Percentage of patients aged 18 years and older with documentation of a pain assessment including the use of a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present.

    DENOMINATOR: Patients 18 years of age and older on the date of the encounter who presented with orthopedic pain at initial encounter

    NUMERATOR: Number of patients with documented pain assessment including the use of a standardized tool(s) AND a follow-up plan is documented when pain is present

    RATIONALE: This is a straightforward generalization of NQF-316 from back conditions to other orthopedic conditions.

     

    OBERD 10: Quality of Life (VR-12 or PROMIS Global 10) Monitoring

    TYPE: Process

    QUALITY DOMAIN: Effective Clinical Care

    DESCRIPTION: Percentage of patients for whom a quality of life assessment is collected by means of a Patient Reported Outcome Instrument that permits standardized assessment of patient physical and mental health status over time.

    DENOMINATOR: Number of patients age 18 or older

    NUMERATOR: Number of patients age 18 or older completing a VR-12 or PROMIS Global 10 survey on one or more occasions during reporting period

    RATIONALE: Quality of life follow-up is fundamental to meaningful health care quality improvement. Such a process is already required for 2014 EHR Incentives in cases of TKA and THA. The two forms selected here are recommended (in CMS66v2 and CMS56v2) and both permit comparisons with national norms. VR-12 permits a finer-grained risk assessment (comorbidities, age, etc.) and the calculation of a utility score (VR-6D) that has been used, inter alia, in the evaluation of the Medicare Advantage plans.

     

    OBERD 11: Quality of Life (VR-12 or PROMIS Global 10) Outcomes

    QUALITY DOMAIN: Effective Clinical Care

    TYPE: Outcome

    DESCRIPTION: Tracking change in health-related quality of life scores at regular intervals following an initial baseline assessment that occurred prior to an intervention. Data will be retained for reference and use for at least 7 years. A score is recorded for each administration of the PRO instrument during a measurement period, as is each intervention. For convenience, the accumulating data for a patient presented in several different ways, including:

    • Graph of all scores plotted against time, with each intervention marked on the time axis
    • Plot of each score against interval since intervention to permit easy aggregation of scores of all patients
    • Plots similar to the above but showing each score minus initial score, to reflect changes from baseline
    • Bar graphs showing the change since last score
    • Tables which collect the foregoing information for all patients of the provider in CSV format for further analysis risk-adjusted versions of the foregoing whenever appropriate methods exist

    DENOMINATOR: Risk adjustment factor as appropriate

    NUMERATOR: Raw scores

    RATIONALE: Supplementing clinician observations and functional PROs with HRQoL evaluation by the patient provides a more complete picture of the quality of medical interventions. The two alternatives offered here have already been recommended in CMS66v2 and CMS56v2 for monitoring knee and hip arthroscopy respectively. The VR-12 permits calculation of a utility score, the VR-6D, which places all medical specialties on the same scale. VR-12 has been employed by both CMS and the VA for a number of years and has been administered to millions of individuals.  The PROMIS approach, based on item response theory and driven by well-researched item banks, offers another option of growing importance. It incorporates extensive normative data (t-scores are calculated) and it has shown the ability to predict utility scores.

     

    OBERD 12: CG-CAHPS Adult Visit Composite Tracking

    QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

    TYPE: Process

    DESCRIPTION: Percentage of all patients age 18 or older answering sufficient questions to address the four operationally defined CG-CAHPS composites.

    DENOMINATOR: Number of patients of age 18 or older

    NUMERATOR: Number of patients age 18 or older completing at least one CG-CAHPS Adult Visit survey including responses to the questions comprising the following composites:

    • Getting Timely Appointments, Care, and Information
    • How Well Providers Communicate With Patients
    • Helpful, Courteous, and Respectful Office Staff
    • Follow-up on Test Results

    RATIONALE: The use of CG-CAHPS is explicitly recognized by PQRS, replacing the discontinued PQRS-321 measure. Additional information is scheduled for release in Spring 2014, but is not available at this writing. The measure proposed here is intended to encourage the administration of CG-CAHPS to all patients at each visit and to ensure that attention is focused on the actionable items in the survey, as summarized in four of the composites. The Adult Visit is the recommended form for three reasons. First, in speaking to the most recent visit, the experience is more clearly in mind; second, the responses are more easily used and evaluated by providers because it speaks to the current situation; and, third, because the 6-month or 12-month data can be approximated by compiling the last-visit information.

     

    OBERD 13: Orthopedic Functional and Pain Level Outcomes

    TYPE: Outcome

    QUALITY DOMAIN: Effective Clinical Care

    DESCRIPTION: Functional changes, including pain level changes, as a result of interventions on particular joints and with particular diagnoses will be addressed in the same way as QoL scores are handled in item 11 above, except that the provider is permitted to choose any PRO instrument validated for the joint in question

    DENOMINATOR: Risk adjustment factor as appropriate

    NUMERATOR: Raw score

    RATIONALE: Not specifying the forms to use has the disadvantages of small sample sizes and missed opportunities for comparison of providers. However, it is proposed that there should be a measure which brings the wisdom of the doctor into the process and which preserves the ability of the doctor to build upon data that has been gathered in the past.

     

    OBERD 14: Orthopedic 3-Month Surgery Follow-up

    QUALITY DOMAIN: Effective Clinical Care

    TYPE: Process

    DESCRIPTION: The measurement is the percent of patients receiving both a pre-operative and a post-operative administration of a PRO instrument validated for measuring functional status of orthopedic surgery patients. The pre-op must be administered no more than two weeks prior to surgery and the post-op must be administered within two-weeks of the three month anniversary of the surgery.

    DENOMINATOR: All patients age 18 or older who received surgery between Jan 15 and Sept 15 OR who received surgery between Jan 1 and Jan 15 and have a pre-op available OR who received a surgery between Sept 15 and Oct 15 and have a post-op available

    NUMERATOR: Patients in the denominator who have both a pre-op and post-op administration of the same validated instrument, such that the pre-op was administered no more than two weeks prior to surgery and the post-op was administered within two-weeks of the three month anniversary of the surgery

    RATIONALE: This process measure elucidates the extent to which changes in functional status of patients receiving surgical intervention are being tracked. The protocol chosen is designed to provide the maximum information for systematic quality improvement, employing a validated PRO instrument. The three-month follow-up period is very common in surgical practice, and can reasonably be accomplished within a yearlong measurement period for a high percentage of patients. The protocol specifies that the data required must be collected within two weeks of the nominal end-points of the follow-up period: pre-op may precede surgery by up to two weeks, and post-op may occur roughly 2.5 to 3.5 months later. This flexibility means that if surgery occurs near the beginning or end of the measurement period, valid data gathering may fall outside of the measurement period for some patients. Such patients are excluded from the denominator by an exclusion and two exceptions, expressed as “OR” conditions in the denominator definition above.

     

    OBERD 15: Orthopedic 3-Month Surgery Outcome

    TYPE: Outcome

    QUALITY DOMAIN: Effective Clinical Care

    Type: Outcome

    DESCRIPTION: This measure reports the average change in score for all patients whose functional status can be measured by a particular validated PRO instrument, over a three-month period following surgery. Pre-op and post-op definitions are the same as in OBERD 14.

    PATIENT POPULATION: All patients age 18 or older who received surgery between Jan 1 and Dec 31 for whom both pre-op and 3-month post-op scores are available

    MEASURE CALCULATION: The measure reported is the average of the difference between pre-op and post-op score for each for each patient in the population:

    M = AVG [post-op – pre-op | patient i]

    The average pre-op score is utilized in determining a risk adjustment based on OBERD QCDR data, and the standard deviation of the set of 3-month changes is also computed.

    RATIONALE: When patient status is being tracked following a clear protocol, as in OBERD 14, a variety of analyses may be performed on the data. This measure is the most basic such analysis, the average change in raw score of a validated instrument over a (nominal) three month period. This advances the quality agenda in several ways. Most important of these is to help habituate the provider to thinking quantitatively about the efficacy of his or her interventions across his entire practice for the year. A ready target is provided to stimulate the human desire to improve.

     

    OBERD 16: Orthopedic 3-Month Surgery Success Rate

    QUALITY DOMAIN: Effective Clinical Care

    TYPE: Outcome

    DESCRIPTION: This measure reports the percentage of all patients showing measurable improvement between pre-op and 3 month post-op score on the basis of a validated PRO instrument for which OBERD QCDR has established a Minimum Detectable Change (MDC) or a Minimum Clinically Important Difference (MCID). Percentages are calculated for both MDC and MCID if both are available for the PRO employed.

    DENOMINATOR: Patients 18 or older who have had surgery between Jan 1 and Dec 31 and have a pre-op and a 3-month post-op score available on the basis of a validated PRO instrument for which OBERD QCDR has established a Minimum Detectable Change (MDC) or a Minimum Clinically Important Difference (MCID)

    NUMERATOR 1: Patients for whom post-op > pre-op + MDC

    NUMERATOR 2: Patients for whom post-op > pre-op + MCID

    RATIONALE: Every measuring instrument has a limit to its precision, and this is certainly true of PRO instruments. Nonetheless, many commonly used outcome instruments do not carefully address this point, and in fact are hardly measuring anything in the sense that measurement is understood in the physical sciences. This measure is designed to acquaint providers with this issue by using best practice to answer the most basic treatment question: did patients get better? The first step is that an instrument may not be used unless OBERD QCDR has verified that its precision has been properly determined, usually by reference to the peer-reviewed literature. The MDC is the minimum change that can be regarded as “real”. Although it can be inferred by statistical analysis of collected data, it is not a 95% confidence interval or the like; rather, nothing at all can be inferred about the relative size of two individual measurements that differ by less than the MDC.

    A second consideration is whether there is medical significance to the difference even though the difference is objectively real. The scales in most clinics can provide a person’s weight correct to about 0.1 pounds, i.e. MDC is 0.1 lb. But for a particular healthcare purpose, a change in weight might be disregarded if it is less than 5 pounds; the MCID would therefore be 5 lbs. The best instruments are those for which both MCD and MCID are known: the first shows if progress is being made, the second shows if it is enough to be important to patients. This measure reports both if available, but an instrument may be used if either is known.

     

    OBERD 17: CG-CAHPS Patient Rating

    QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

    TYPE: Outcome

    DESCRIPTION: This measure reports the 7 CG-CAHPS composite scores for patients 18 or older who have completed the CG-CAHPS v3 during the measurement period: if completed more than once, the scores are averaged. The scores reflect the percentage of forms on which the provider received the “top box” rating for each composite.

    DENOMINATOR: The total number of forms completed during the measurement period by patients 18 or older

    NUMERATOR k: The sum of all scores reported for the k-th composite, k = 1 to 7

    RATIONALE: This measure is designed to promote the use of a standardized patient satisfaction instrument. The composites have been selected by CMS and the CAHPS developers to summarize the results of a 34 question (31 questions if v3 is approved as expected in early 2015) into seven helpful “dimensions.” The scores are easily understood, and national summaries are produced. Regrettably, this analysis is not completed for roughly nine months after the year-end, but the preceding year’s scores can provide a close approximation for the use of the provider.

     

    OBERD 18: ORTHOPEDIC 3-MONTH SURGERY OUTCOME WITH PROMIS

    QUALITY DOMAIN: Effective Clinical Care

    TYPE: Outcome

    DESCRIPTION: OBERD QCDR includes a completely imbedded PROMIS CAT system in order to provide these instruments to its participants in a manner identical to all its other web-based data collection facilities. The measures that utilize these instruments have the same structure as any other OBERD QCDR outcome measure, plus the additional benefit of scores referenced to national norms.

    PATIENT POPULATION: All patients age 18 or older who received surgery between Jan 1 and Dec 31 for whom both pre-op and 3-month post-op scores are available using the relevant PROMIS item bank

    MEASURE CALCULATION: The measure reported is the average of the difference between pre-op and post-op score for each for each patient in the population:

    M = AVG [post-op – pre-op | patient i]

    The average pre-op score is utilized in determining a risk adjustment based on the general population. The standard deviation of the set of differences is also reported.

    RATIONALE: The PROMIS Consortium, extensively funded by NIH over several years, is in the process of releasing question banks that address functioning of various joints and musculoskeletal systems of interest to orthopedists. The PROMIS approach is distinguished by three features common to all its instruments: it employs computer adaptive testing (CAT) methods to reduce the required number of questions (significantly reducing the burden on patients); its scales are linearized using Item Response Theory (IRT); and it is normed against the U.S. general population and scaled so that the average for the population is 50 and the standard deviation is 10. The PROMIS scores are broadly applicable, and PROMIS deserves to be widely known and used where appropriate.

     

    OBERD 19: Orthopedic Surgery 3-Month QoL Changes (VR-6D)

    QUALITY DOMAIN: Population and Public Health

    TYPE: Outcome

    DESCRIPTION: This measure calculates the effect of surgery on Quality of Life after 3 months based on the pre-op and post-op values of the VR-6D utility scale.

    PATIENT POPULATION: All patients 18 or older for whom a VR-6D score can be calculated both pre-operatively and 3-months post-operatively

    MEASURE CALCULATION: The measure reported is the average of the difference between pre-op and post-op VR-6D for each for each patient in the population:

    M = AVG [post-op – pre-op | patient i]

    The average pre-op score is utilized in determining a risk adjustment based on national data, and the standard deviation of the set of 3-month changes is also computed.

    RATIONALE: A utility value (sometimes called patient “preference”) is reported on a 0 to 1 scale, measures quality of life rather than physical or mental function per se, is intended to permit comparisons across medical specialties, and is derived by interviewing a sample of the population using either a “time trade-off” or “standard gamble” methodology. Utility scores are used as a weighting factor to include quality of life in the calculation of the benefit of a medical treatment, as well as the duration of the efficacy of the treatment, by way of the Quality of Life Year (the “Qaly”). The VR-6D has been widely used in CMS studies as well as by the Veterans Administration, which initiated its development. It provides another distinct view to the provider of the quality of care being provided.

     

     

    OBERD 20: Orthopedic Surgery 3-Month QoL Changes (EQ-5D)

    QUALITY DOMAIN: Population and Public Health

    TYPE: Outcome

    DESCRIPTION: This measure calculates the effect of surgery on Quality of Life after 3 months based on the pre-op and post-op values of the EQ-5D utility scale, developed by the EuroQoL group, now headquartered in Amsterdam.

    PATIENT POPULATION: All patients 18 or older for whom a EQ-5D score can be calculated both pre-operatively and 3-months post-operatively

    MEASURE CALCULATION: The measure reported is the average of the difference between pre-op and post-op EQ-5D for each for each patient in the population:

    M = AVG [post-op – pre-op | patient i]

    The average pre-op score is utilized in determining a risk adjustment based on national data, and the standard deviation of the set of 3-month changes is also computed.

    RATIONALE: A utility value is reported on a 0 to 1 scale, measures quality of life rather than physical or mental function per se, is intended to permit comparisons across medical specialties, and is derived from interviews based on “time trade-off” or “standard gamble” methodologies. Utility scores are used as a weighting factor to include quality of life to the calculation of the benefit of a medical treatment, as well as the duration of the efficacy of the treatment, by way of the Quality of Life Year (the “Qaly”). EQ-5D is widely used in Europe, and its U.S, use is on the rise

     

    OBERD 21: Provider Follow-up of Patient Post-acute Self-care

    QUALITY DOMAIN: Communication and Care Coordination

    TYPE: Process

    DESCRIPTION: When patients are released to their own care following treatment for an acute condition, there is an increased risk of avoidable adverse events requiring readmission or other additional treatment. This measure tracks preventive follow-up by the provider office.

    DENOMINATOR: Number of patients age 18 or older released from clinic, hospital, or other provider care on their own recognizance.

    EXCLUSIONS: Any patients receiving care from healthcare professionals (e.g. SNF, HCA, rehab facility, etc.) in the first post-acute week

    NQF ID Number: 0

    RATIONALE: With the trend toward shortened hospital stays, patients are increasingly released by the provider to his or her own care or that of the person’s family. Even with the use of SNFs, HCA, and in-patient rehab, nearly 20% of Medicare hospitalizations are readmissions. Fortunately, there is good evidence that provider contact with the patient at home during the days following release can help detect adverse events early enough to reduce the patient suffering and the costs that these events entail. Moreover, there is evidence that technology is effective in reducing the burden on the provider.. This measure is intended to encourage patient contact, and especially to emphasize the use of appropriate technology*.

    Ref: Graham, et al, Med Care 2012;50: 50–57

    *(For instance the OBERD QCDR can automate the implementation, tracking and verification of the entire process if electronic communications are used.)

  • PQRS MEASURES

    PQRS # 21, 22, 23, 24, 111, 128, 130, 154, 155, 163, 226, 236, 238, 317, 318, 370, 371, 373, 375, 376

    PQRS 021: Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second-Generation Cephalosporin

    Type: Process

    Quality Domain: Patient Safety

    Description: Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for a first OR second-generation cephalosporin for antimicrobial prophylaxis.

    Measure Developer/Steward: AMA-PCPI / NCQA

     

    PQRS 022: Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Non-Cardiac Procedures)

    Type: Process

    Quality Domain: Patient Safety

    Description: Percentage of non-cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics AND who received a prophylactic parenteral antibiotic, who have an order for discontinuation of prophylactic parenteral antibiotics within 24 hours of surgical end time.

    Measure Developer/Steward: AMA-PCPI / NCQA

     

    PQRS 023: Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients

    Type: Process

    Quality Domain: Patient Safety

    Description: Percentage of surgical patients aged 18 years and older undergoing procedures for which VTE prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time.

    Measure Developer/Steward: AMA-PCPI / NCQA

     

    PQRS 024: Osteoporosis: Communication with the Physician Managing On-going Care Post-Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older

    Type: Process

    Quality Domain: Communication and Care Coordination

    Description: Percentage of patients aged 50 years and older treated for a hip, spine or distal radial fracture with documentation of communication with the physician managing the patient’s on-going care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis.

    Measure Developer/Steward: NCQA

     

    PQRS 111: Pneumonia Vaccination Status for Older Adults

    Type: Process

    Quality Domain: Community/Population Health

    Description: Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.

    Measure Developer/Steward: NCQA

     

    PQRS 128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

    Type: Process

    Quality Domain: Community/Population Health

    Description: Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter.

    Normal Parameters: Age 65 years and older BMI ≥ 23 and < 30 kg/m2; Age 18 – 64 years BMI ≥ 18.5 and < 25 kg/m2

    Measure Developer/Steward: CMS / QIP

     

    PQRS 130: Documentation of Current Medications in the Medical Record

    Type: Process

    Quality Domain: Patient Safety

    Description: Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.

    Measure Developer/Steward: CMS / QIP

     

    PQRS 154: Falls: Risk Assessment

    Type: Process

    Quality Domain: Patient Safety

    Description: Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months.

    Measure Developer/Steward: NCQA / AMA-PCPI

     

    PQRS 155: Falls: Plan of Care

    Type: Process

    Quality Domain: Patient Safety

    Description: Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months.

    Measure Developer/Steward: NCQA / AMA-PCPI

     

    PQRS 163: Diabetes: Foot Exam

    Type: Process

    Quality Domain: Effective Clinical Care

    Description: Percentage of patients aged 18-75 years of age with diabetes who had a foot exam during the measurement period.       

    Measure Developer/Steward: NCQA

     

    PQRS 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

    Type: Process

    Quality Domain: Community/Population Health

    Description: 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.

    Measure Developer/Steward: AMA-PCPI

     

    PQRS 236: Controlling High Blood Pressure

    Type: Intermediate Outcome

    Quality Domain: Effective Clinical Care

    Description: Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mmHg) during the measurement period.

    Measure Developer/Steward: NCQA

     

    PQRS 238: Use of High-Risk Medications in the Elderly

    Type: Process

    Quality Domain: Patient Safety

    Description: Percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported.

    1. Percentage of patients who were ordered at least one high-risk medication
    2. Percentage of patients who were ordered at least two different high-risk medications

    Measure Developer/Steward: NCQA

     

    PQRS 317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

    Type: Process

    Quality Domain: Community/Population Health

    Description: 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.

    Measure Developer/Steward: CMS / QIP

     

    PQRS 318: Falls: Screening for Fall Risk

    Type: Process

    Quality Domain: Patient Safety

    Description: Percentage of patients 65 years of age and older who were screened for future fall risk at least once during the measurement period.

    Measure Developer/Steward: NCQA

     

    PQRS 371: Depression Utilization of the PHQ-9 Tool

    Type: Process

    Quality Domain: Effective Clinical Care

    Description: 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.

    Measure Developer/Steward: MNCM

     

    PQRS 373: Hypertension: Improvement in Blood Pressure

    Type: Intermediate Outcome

    Quality Domain: Effective Clinical Care

    Description: Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period.

    Measure Developer/Steward: CMS / NCQA

     

    PQRS 375: Functional Status Assessment for Knee Replacement

    Type: Process

    Quality Domain: Person and Caregiver-Centered Experience and Outcomes

    Description: 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.

    Measure Developer/Steward: CMS / NCQA

     

    PQRS 376: Functional Status Assessment for Hip Replacement

    Type: Process

    Quality Domain: Person and Caregiver-Centered Experience and Outcomes

    Description: 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.

    Measure Developer/Steward: CMS / NCQA