ecqm.measure

CMS22v7 - Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

Rationale:

Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented. Hypertension is a prevalent condition that affects approximately 66.9 million people in the United States. It is estimated that about 20-40% of the adult population has hypertension; the majority of people over age 65 have a hypertension diagnosis (Appleton SL, et. al., 2012 and Luehr D, et. al., 2012). Winter (2013) noted that 1 in 3 American adults have hypertension and the lifetime risk of developing hypertension is 90% (Winter KH, et. al., 2013). The African American population or non-Hispanic Blacks, the elderly, diabetics and those with chronic kidney disease are at increased risk of stroke, myocardial infarction and renal disease. Non-Hispanic Blacks have the highest prevalence at 38.6% (Winter KH, et. al., 2013). Hypertension is a major risk factor for ischemic heart disease, left ventricular hypertrophy, renal failure, stroke and dementia (Luehr D, et. al., 2012). Hypertension is the most common reason for adult office visits other than pregnancy. Garrison (2013) stated that in 2007, 42 million ambulatory visits were attributed to hypertension (Garrison GM and Oberhelman S, 2013). It also has the highest utilization of prescription drugs. Numerous resources and treatment options are available, yet only about 40-50% of the hypertensive patients have their blood pressure under control (<140/90) (Appleton SL, et. al., 2012, Luehr D, et. al., 2012). In addition to medication non-compliance, poor outcomes are also attributed to poor adherence to lifestyle changes such as a low-sodium diet, weight loss, increased exercise and limiting alcohol intake. Many adults find it difficult to continue medications and lifestyle changes when they are asymptomatic. Symptoms of elevated blood pressure usually do not occur until secondary problems arise such as with vascular diseases (myocardial infarction, stroke, heart failure and renal insufficiency) (Luehr D, et. al., 2012). Appropriate follow-up after blood pressure measurement is a pivotal component in preventing the progression of hypertension and the development of heart disease. Detection of marginally or fully elevated blood pressure by a specialty clinician warrants referral to a provider familiar with the management of hypertension and prehypertension. The 2010 ACCF/AHA Guideline for the Assessment of Cardiovascular Risk in Asymptomatic Adults continues to support using a global risk score such as the Framingham Risk Score, to assess risk of coronary heart disease (CHD) in all asymptomatic adults (Greenland P, et. al., 2010). Lifestyle modifications have demonstrated effectiveness in lowering blood pressure (JNC 7, 2003). The synergistic effect of several lifestyle modifications results in greater benefits than a single modification alone. Baseline diagnostic/laboratory testing establishes if a co-existing underlying condition is the etiology of hypertension and evaluates if end organ damage from hypertension has already occurred. Landmark trials such as ALLHAT have repeatedly proven the efficacy of pharmacologic therapy to control blood pressure and reduce the complications of hypertension. Follow-up intervals based on blood pressure control have been established by the JNC 7 and the USPSTF.

Data Elements

DiagnosisOfHypertensionDiagnosis

Clinical Focus: This set of values contains situations or actual assessment findings where the diagnosis of hypertension is currently documented in the medical record.

Data Element Scope:

Inclusion Criteria: Includes diagnoses that hypertension is ultimately present in, such as renal disease, pregnancy (pre-eclampsia, pregnancy induced hypertension

Exclusion Criteria:

ResultValue constrained to codes in the Diagnosis of hypertension valueset (2.16.840.1.113883.3.600.263)

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

DiagnosisOfHypertensionDiagnosis

0..*

Ecg12LeadOrStudyOrderOrder

Clinical Focus: The primary purpose of this value set is capture that a 12 lead EKG was ordered by the health care provider.

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the ECG 12 lead or study order

DiagnosticStudyOrder: Data elements that meet criteria using this datatype should document a request by a clinician or appropriately licensed care provider to an appropriate provider or organization to perform the diagnostic study indicated by the QDM category and its corresponding value set. The request may be in the form of a consultation or a direct order to the organization that performs the diagnostic study. Diagnostic studies are those that are not performed in the clinical laboratory. Such studies include but are not limited to imaging studies, cardiology studies (electrocardiogram, treadmill stress testing), pulmonary function testing, vascular laboratory testing, and others. Timing: The time the order is signed; Author dateTime.

DataType

Cardinality

Ecg12LeadOrStudyOrderOrder

0..*

PatientReasonRefusedNegationRationale

Clinical Focus: This set of values contains situations in which a patient may refuse a treatment or service.

Data Element Scope:

Inclusion Criteria: Included are situations related to a treatment or procedure refused, or refusal due to religion or non-compliance.

Exclusion Criteria:

NegationRationale: Indicates the reason that an action was not performed. Only QDM datatypes that represent actions (e.g., performed, recommended, communication, order, dispensed) allow the “negation rationale” attribute. The intent is to indicate a justification that such action did not happen as expected. This attribute specifically does not address the presence or absence of information in a clinical record (e.g., documented absence of allergies Vs lack of documentation about allergies). The syntax in the human readable HQMF is address in CQL examples and in the MAT User Guide. Prior versions of QDM used the syntax, “Procedure, Performed not done.” QDM 5.0 DRAFT uses the syntax, “Procedure, not Performed.” Note: Some datatypes include both Relevant Time and Author dateTime attributes. The purpose is to accommodate Author dateTime if the actual start and stop times are not available when evaluating for feasibility, and also to allow specification of a time for Negation Rationale.

DataType

Cardinality

PatientReasonRefusedNegationRationale

0..*

BpScreeningEncounterCodesPerformed

Clinical Focus: This set of values contains encounters where a blood pressure could be performed and documented.

Data Element Scope:

Inclusion Criteria: Includes examinations, assessments, evaluations, or procedure encounters where the actual procedure of taking a blood pressure is performed.

Exclusion Criteria:

Subject constrained to the BP Screening Encounter Codes

EncounterPerformed: Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed. Timing: The Relevant Period addresses: startTime – The time the encounter began (admission time) stopTime – The time the encounter ended (discharge time). The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained. The Location Period is an attribute of the attribute facility location addresses: startTime = the time the patient arrived at the location; stopTime = the time the patient departed from the location

DataType

Cardinality

BpScreeningEncounterCodesPerformed

0..*

ReferralToAlternativeProviderPrimaryCareProviderOrder

Clinical Focus: This set of values incorporates that a referral to another physician or practitioner, service, or clinic is documented by the primary care provider.

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Referral to Alternative Provider / Primary Care Provider

InterventionOrder: Data elements that meet criteria using this datatype should document a request to perform the intervention indicated by the QDM category and its corresponding value set. Timing: The time the order is signed; Author dateTime

DataType

Cardinality

ReferralToAlternativeProviderPrimaryCareProviderOrder

0..*

LifestyleRecommendationOrder

Clinical Focus: This set of values contains lifestyle education related to hypertension that is documented by the health care professional.

Data Element Scope:

Inclusion Criteria: Included is education provided regarding lifestyle modification as related to the diagnosis or finding of hypertension.

Exclusion Criteria:

Subject constrained to the Lifestyle Recommendation

InterventionOrder: Data elements that meet criteria using this datatype should document a request to perform the intervention indicated by the QDM category and its corresponding value set. Timing: The time the order is signed; Author dateTime

DataType

Cardinality

LifestyleRecommendationOrder

0..*

WeightReductionRecommendedOrder

Clinical Focus: The general purpose of this value set is that obesity or the need to reduce weight is assessed, so that a target weight discussion can take place, or weight reduction education is provided, or a referral to a weight management program was given; also weight management classes could be ordered to be performed by a non- physician provider.

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Weight Reduction Recommended

InterventionOrder: Data elements that meet criteria using this datatype should document a request to perform the intervention indicated by the QDM category and its corresponding value set. Timing: The time the order is signed; Author dateTime

DataType

Cardinality

WeightReductionRecommendedOrder

0..*

DietaryRecommendationsOrder

Clinical Focus: This set of values incorporates dietary referrals, diet education or diet recommendation, or nutritional counseling that is documented as discussed or ordered by the health care provider.

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Dietary Recommendations

InterventionOrder: Data elements that meet criteria using this datatype should document a request to perform the intervention indicated by the QDM category and its corresponding value set. Timing: The time the order is signed; Author dateTime

DataType

Cardinality

DietaryRecommendationsOrder

0..*

PhysicalActivityRecommendationOrder

Clinical Focus: This set of values indicates that education, recommendation, or counseling was given in order to increase physical activity as necessary.

Data Element Scope:

Inclusion Criteria: Nutritional therapy, encouragement to exercise, and actual prescribed exercise is included in this set of values.

Exclusion Criteria:

Subject constrained to the Physical Activity Recommendation

InterventionOrder: Data elements that meet criteria using this datatype should document a request to perform the intervention indicated by the QDM category and its corresponding value set. Timing: The time the order is signed; Author dateTime

DataType

Cardinality

PhysicalActivityRecommendationOrder

0..*

ModerationOfEtohConsumptionRecommendationOrder

Clinical Focus: This set of values contains lifestyle modification issues in relation to alcohol consumption; that alcoholism was addressed through education, counseling, or referral.

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Moderation of ETOH Consumption Recommendation

InterventionOrder: Data elements that meet criteria using this datatype should document a request to perform the intervention indicated by the QDM category and its corresponding value set. Timing: The time the order is signed; Author dateTime

DataType

Cardinality

ModerationOfEtohConsumptionRecommendationOrder

0..*

FollowupWithinOneYearOrder

Clinical Focus: This set of values is meant to collect data that a follow-up encounter or visit was written or scheduled within the time period of one year of the initial encounter.

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Followup within one year

InterventionOrder: Data elements that meet criteria using this datatype should document a request to perform the intervention indicated by the QDM category and its corresponding value set. Timing: The time the order is signed; Author dateTime

DataType

Cardinality

FollowupWithinOneYearOrder

0..*

FollowupWithin4WeeksOrder

Clinical Focus: This set of values is meant to capture that a follow-up encounter or visit is in place within four weeks of the initial encounter.

Data Element Scope:

Inclusion Criteria: Included are codes addressing that the follow-up was completed anywhere from 1 day to 1 month of the initial finding.

Exclusion Criteria:

Subject constrained to the Followup within 4 weeks

InterventionOrder: Data elements that meet criteria using this datatype should document a request to perform the intervention indicated by the QDM category and its corresponding value set. Timing: The time the order is signed; Author dateTime

DataType

Cardinality

FollowupWithin4WeeksOrder

0..*

LaboratoryTestsForHypertensionOrder

Clinical Focus: This set of values contains laboratory tests, including a series of panels and urine testing that may be collected in patients that have a diagnosis of hypertension.

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Laboratory Tests for Hypertension

LaboratoryTestOrder: Data elements that meet criteria using this datatype should document a request for the laboratory test indicated by the QDM category and its corresponding value set. Timing: The time the order is signed; Author dateTime.

DataType

Cardinality

LaboratoryTestsForHypertensionOrder

0..*

AntiHypertensivePharmacologicTherapyOrder

Clinical Focus: This value set contains medications that are commonly used to reduce blood pressure in patients that have a diagnosis of hypertension.

Data Element Scope:

Inclusion Criteria: Included are medications and dosages commonly prescribed for the treatment of hypertension.

Exclusion Criteria:

Subject constrained to the Anti-Hypertensive Pharmacologic Therapy

MedicationOrder: Data elements that meet criteria using this datatype should document a request to a pharmacy to provide the medication indicated by the QDM category and its corresponding value set. Timing: The Author dateTime is the time the order is signed. Timing: The Relevant Period addresses: startTime = when the first administration of the medication is expected. The first administration may be expected at the time of the order or at a specified future date (i.e., the active time for the order); such information should be identified in the medication order. If the startTime is not specified in the order, the startTime defaults to the Author dateTime (the time the order is signed). stopTime = when the medication supply provided by the medication order is expected to be completed, including all fulfillments covered by the number of refills. Note that when calculating cumulative medication duration, the stopTime may be present directly in the medication order. If the stopTime is not available, the duration in days is the difference between the Relevant Period start and stop times multiplied by (1 + the number of refills). Refer to Special Cases in Appendix A (Section A.3) for scenarios to consider in calculating cumulative medication duration.

DataType

Cardinality

AntiHypertensivePharmacologicTherapyOrder

0..*

EthnicityPatientCharacteristicEthnicity

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ResultValue constrained to codes in the Ethnicity valueset (2.16.840.1.114222.4.11.837)

PatientCharacteristicEthnicity: Data elements that meet criteria using this datatype should document that the patient has one or more of the ethnicities indicated by the QDM category and its corresponding value set. Timing: Ethnicity does not have a specific timing. Measures using Patient Characteristic, Ethnicity should address the most recent entry in the clinical record.

DataType

Cardinality

EthnicityPatientCharacteristicEthnicity

0..*

OncAdministrativeSexPatientCharacteristicGender

Clinical Focus: Gender identity restricted to only Male and Female used in administrative situations requiring a restriction to these two categories.

Data Element Scope: Gender

Inclusion Criteria: Male and Female only.

Exclusion Criteria: Any gender identity that is not male or female.

ResultValue constrained to codes in the ONC Administrative Sex valueset (2.16.840.1.113762.1.4.1)

PatientCharacteristicGender: Data elements that meet criteria using this datatype should document that the patient's sex matches the QDM category and its corresponding value set. Timing: Birth (administrative) sex does not have a specific timing.

DataType

Cardinality

OncAdministrativeSexPatientCharacteristicGender

0..*

PayerPatientCharacteristicPayer

Clinical Focus: Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system

Data Element Scope: @code in CCDA r2.1 template Planned Coverage [act: identifier urn:oid:2.16.840.1.113883.10.20.22.4.129 (open)] DYNAMIC

Inclusion Criteria: All codes in the code system

Exclusion Criteria: none

ResultValue constrained to codes in the Payer valueset (2.16.840.1.114222.4.11.3591)

PatientCharacteristicPayer: Data elements that meet criteria using this datatype should document that the patient has one or more of the payers indicated by the QDM category and its corresponding value set. Timing: The Relevant Period addresses: startTime – The first day of insurance coverage with the referenced payer stopTime – The last day of insurance coverage with the referenced payer

DataType

Cardinality

PayerPatientCharacteristicPayer

0..*

RacePatientCharacteristicRace

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ResultValue constrained to codes in the Race valueset (2.16.840.1.114222.4.11.836)

PatientCharacteristicRace: Data elements that meet criteria using this datatype should document the patient’s race. Timing: Race does not have a specific timing. Measures using Patient Characteristic, Race should address the most recent entry in the clinical record.

DataType

Cardinality

RacePatientCharacteristicRace

0..*

DiastolicBloodPressurePerformed

PhysicalExamPerformed: Data elements that meet criteria using this datatype should document the completion of the physical exam indicated by the QDM category and its corresponding value set. Timing: The Relevant Period addresses: startTime – The time the physical examination activity begins. stopTime – The time the physical examination activity ends. NOTE - timing refers to a single instance of a physical examination activity. If a measure seeks to evaluate multiple physical examination activities over a period of time, the measure developer should use CQL logic to represent the query request.

DataType

Cardinality

DiastolicBloodPressurePerformed

0..*

SystolicBloodPressurePerformed

PhysicalExamPerformed: Data elements that meet criteria using this datatype should document the completion of the physical exam indicated by the QDM category and its corresponding value set. Timing: The Relevant Period addresses: startTime – The time the physical examination activity begins. stopTime – The time the physical examination activity ends. NOTE - timing refers to a single instance of a physical examination activity. If a measure seeks to evaluate multiple physical examination activities over a period of time, the measure developer should use CQL logic to represent the query request.

DataType

Cardinality

SystolicBloodPressurePerformed

0..*