2020 Telehealth-related Quality Measures: CQMs

With the advent of COVID-19 pandemic outbreak, we recognize that a significant amount of healthcare is now being delivered via telehealth. Identifying those measures which are relevant to telehealth will help many providers successfully report relevant measures as they shift to participating in telehealth.

Quality IdMeasure NameMeasure TypeMeasure Description
001Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)Intermediate OutcomePercentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.View
024Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and OlderProcessPercentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is submitted by the physician who treats the fracture and who therefore is held accountable for the communicationView
039Screening for Osteoporosis for Women Aged 65-85 Years of AgeProcessPercentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosisView
047Advance Care PlanProcessPercentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care planView
048Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and OlderProcessPercentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 monthsView
050Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and OlderProcessPercentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 monthsView
065Appropriate Treatment for Children with Upper Respiratory Infection (URI)ProcessPercentage 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 episodeView
066Appropriate Testing for Children with PharyngitisProcessPercentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episodeView
111Pneumococcal Vaccination Status for Older AdultsProcessPercentage of patients 65 years of age and older who have ever received a pneumococcal vaccineView
112Breast Cancer ScreeningProcessPercentage of women 50 - 74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the measurement period.View
113Colorectal Cancer ScreeningProcessPercentage of patients 50-75 years of age who had appropriate screening for colorectal cancer.View
116Avoidance of Antibiotic Treatment in Adults With Acute BronchitisProcessThe percentage of adults 18–64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescriptionView
117Diabetes: Eye ExamProcessPercentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy overlapping the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or diabetics with no diagnosis of retinopathy overlapping the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or in the 12 months prior to the measurement period.View
119Diabetes: Medical Attention for NephropathyProcessThe percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period.View
130Documentation of Current Medications in the Medical RecordProcessPercentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician 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 administrationView
134Preventive Care and Screening: Screening for Depression and Follow-Up PlanProcessPercentage of patients aged 12 years and older screened for 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 screenView
154Falls: Risk AssessmentProcessPercentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 monthsView
155Falls: Plan of CareProcessPercentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 monthsView
182Functional Outcome AssessmentProcessPercentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficienciesView
205HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and SyphilisProcessPercentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea, and syphilis screenings were performed at least once since the diagnosis of HIV infectionView
217Functional Status Change for Patients with Knee ImpairmentsPatient Reported OutcomeA patient-reported outcome measure of risk-adjusted change in functional status for patients aged 14 years+ with knee impairments. The change in functional status (FS) is assessed using the Knee FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).View
218Functional Status Change for Patients with Hip ImpairmentsPatient Reported OutcomeA patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with hip impairments. The change in functional status (FS) is assessed using the Hip FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).View
219Functional Status Change for Patients with Lower Leg, Foot or Ankle ImpairmentsPatient Reported OutcomeA patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with foot, ankle and lower leg impairments. The change in functional status (FS) is assessed using the Foot/Ankle FS patient- reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).View
220Functional Status Change for Patients with Low Back ImpairmentsPatient Reported OutcomeA patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with low back impairments. The change in functional status (FS) is assessed using the Low Back FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).View
221Functional Status Change for Patients with Shoulder ImpairmentsPatient Reported OutcomeA patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with shoulder impairments. The change in functional status (FS) is assessed using the Shoulder FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).View
222Functional Status Change for Patients with Elbow, Wrist or Hand ImpairmentsPatient Reported OutcomeA patient-reported outcome measure of risk-adjusted change in functional status (FS) for patients 14 years+ with elbow, wrist, or hand impairments. The change in FS is assessed using the Elbow/Wrist/Hand FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).View
236Controlling High Blood PressureIntermediate OutcomePercentage of patients 18 - 85 years of age who had a diagnosis of hypertension overlapping the measurement period and whose most recent blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period.View
238Use of High-Risk Medications in the ElderlyProcessPercentage of patients 65 years of age and older who were ordered high-risk medications. Two rates are submitted.
1) Percentage of patients who were ordered at least one high-risk medication
2) Percentage of patients who were ordered at least two of the same high-risk medication
View
275Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) TherapyProcessPercentage of patients with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted prior to initiating anti-TNF (tumor necrosis factor) therapyView
338HIV Viral Load SuppressionOutcomeThe percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement yearView
340HIV Medical Visit FrequencyProcessPercentage of patients, regardless of age with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visitsView
342Pain Brought Under Control Within 48 HoursOutcomePatients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) who report pain was brought to a comfortable level within 48 hoursView
370Depression Remission at Twelve MonthsOutcomeThe percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event date.View
383Adherence to Antipsychotic Medications For Individuals with SchizophreniaIntermediate OutcomePercentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months)View
390Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment OptionsProcessPercentage of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or other qualified healthcare professional reviewed the range of treatment options appropriate to their genotype and demonstrated a shared decision making approach with the patient. To meet the measure, there must be documentation in the patient record of a discussion between the physician or other qualified healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatmentView
394Immunizations for AdolescentsProcessThe percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday.View
398Optimal Asthma ControlOutcomeComposite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbationView
401Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with CirrhosisProcessPercentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month submission periodView
402Tobacco Use and Help with Quitting Among AdolescentsProcessThe percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco userView
418Osteoporosis Management in Women Who Had a FractureProcessThe percentage of women age 50-85 who suffered a fracture in the six months prior to the performance period through June 30 of the performance period and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture.View
441Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)Intermediate OutcomeThe IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator.View
443Non-Recommended Cervical Cancer Screening in Adolescent FemalesProcessThe percentage of adolescent females 16–20 years of age who were screened unnecessarily for cervical cancerView
444Medication Management for People with AsthmaProcessThe percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment periodView
450Trastuzumab Received By Patients With AJCC Stage I (T1c) – III And HER2 Positive Breast Cancer Receiving Adjuvant ChemotherapyProcessProportion of female patients (aged 18 years and older) with AJCC stage I (T1c) – III, human epidermal growth factor receptor 2 (HER2) positive breast cancer receiving adjuvant chemotherapy who are also receiving trastuzumab.View
451RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody TherapyProcessPercentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom RAS (KRAS and NRAS) gene mutation testing was performedView
452Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal AntibodiesProcessPercentage of adult patients (aged 18 or over) with metastatic colorectal cancer and RAS (KRAS or NRAS) gene mutation spared treatment with anti-EGFR monoclonal antibodiesView
453Percentage of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life (lower score – better)ProcessPercentage of patients who died from cancer receiving chemotherapy in the last 14 days of life.View
455Percentage of Patients Who Died from Cancer Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life (lower score – better)OutcomePercentage of patients who died from cancer admitted to the ICU in the last 30 days of life.View
457Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score – better)OutcomePercentage of patients who died from cancer, and admitted to hospice and spent less than 3 days thereView
468Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)ProcessPercentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatmentView
478Functional Status Change for Patients with Neck ImpairmentsPatient Reported OutcomeThis is a patient-reported outcome performance measure (PRO-PM) consisting of a patient-reported outcome measure (PROM) of risk- adjusted change in functional status (FS) for patients aged 14+ with neck impairments. The change in FS is assessed using the Neck FS PROM.* The measure is risk-adjusted to patient characteristics known to be associated with FS outcomes. It is used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.

*The Neck FS PROM is an item-response theory-based computer adaptive test (CAT). In addition to the CAT version, which provides for reduced patient response burden, it is available as a 10-item short form (static/paper-pencil).
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