eCQM Title | Breast Cancer Screening |
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eCQM Identifier (Measure Authoring Tool) | 125 | eCQM Version number | 8.4.000 |
NQF Number | Not Applicable | GUID | 19783c1b-4fd1-46c1-8a96-a2f192b97ee0 |
Measurement Period | January 1, 20XX through December 31, 20XX | ||
Measure Steward | National Committee for Quality Assurance | ||
Measure Developer | National Committee for Quality Assurance | ||
Endorsed By | None | ||
Description | |||
Copyright | |||
Disclaimer | |||
Measure Scoring | Proportion | ||
Measure Type | Process | ||
Stratification | |||
Risk Adjustment | |||
Rate Aggregation | |||
Rationale | |||
Clinical Recommendation Statement | |||
Improvement Notation | |||
Reference | |||
Reference | |||
Reference | |||
Definition | |||
Guidance | |||
Transmission Format | |||
Initial Population | |||
Denominator | |||
Denominator Exclusions | |||
Numerator | |||
Numerator Exclusions | |||
Denominator Exceptions | |||
Supplemental Data Elements |
exists ( ["Patient Characteristic Sex": "Female"] ) and exists ["Patient Characteristic Birthdate": "Birth date"] BirthDate where Global."CalendarAgeInYearsAt"(BirthDate.birthDatetime, start of "Measurement Period")in Interval[51, 74 ) and exists AdultOutpatientEncounters."Qualifying Encounters"
"Initial Population"
Hospice."Has Hospice" or ( Count("Unilateral Mastectomy Procedure")= 2 ) or ( ( exists ( "Right Mastectomy Diagnosis" ) or exists ( "Right Mastectomy Procedure" ) ) and ( exists ( "Left Mastectomy Diagnosis" ) or exists ( "Left Mastectomy Procedure" ) ) ) or exists "Bilateral Mastectomy Diagnosis" or exists "Bilateral Mastectomy Procedure" or FrailtyLTI."Advanced Illness and Frailty Exclusion Including Under Age 80" or ( exists ["Patient Characteristic Birthdate": "Birth date"] BirthDate where ( Global."CalendarAgeInYearsAt"(BirthDate.birthDatetime, start of "Measurement Period")>= 65 ) and FrailtyLTI."Has Spent More Than 90 Days in Long Term Care" )
exists ( ["Diagnostic Study, Performed": "Mammography"] Mammogram where ( Mammogram.relevantPeriod ends 27 months or less before day of end "Measurement Period" ) )
( ["Encounter, Performed": "Office Visit"] union ["Encounter, Performed": "Annual Wellness Visit"] union ["Encounter, Performed": "Preventive Care Services - Established Office Visit, 18 and Up"] union ["Encounter, Performed": "Preventive Care Services-Initial Office Visit, 18 and Up"] union ["Encounter, Performed": "Home Healthcare Services"] ) ValidEncounter where ValidEncounter.relevantPeriod during "Measurement Period"
//If the measure does NOT include populations age 80 and older, then use this logic: exists ( ["Patient Characteristic Birthdate": "Birth date"] BirthDate where Global."CalendarAgeInYearsAt"(BirthDate.birthDatetime, start of "Measurement Period")>= 65 and "Has Criteria Indicating Frailty" and ( Count("Outpatient Encounters with Advanced Illness")>= 2 or exists ( "Inpatient Encounter with Advanced Illness" ) or exists "Dementia Medications In Year Before or During Measurement Period" ) )
"CumulativeDays"("Long Term Care Periods During Measurement Period")
["Medication, Active": "Dementia Medications"] DementiaMed where DementiaMed.relevantPeriod overlaps Interval[( start of "Measurement Period" - 1 year ), end of "Measurement Period"]
exists ( ["Device, Order": "Frailty Device"] FrailtyDeviceOrder where FrailtyDeviceOrder.authorDatetime during "Measurement Period" ) or exists ( ["Device, Applied": "Frailty Device"] FrailtyDeviceApplied where FrailtyDeviceApplied.relevantPeriod overlaps "Measurement Period" ) or exists ( ["Diagnosis": "Frailty Diagnosis"] FrailtyDiagnosis where FrailtyDiagnosis.prevalencePeriod overlaps "Measurement Period" ) or exists ( ["Encounter, Performed": "Frailty Encounter"] FrailtyEncounter where FrailtyEncounter.relevantPeriod overlaps "Measurement Period" ) or exists ( ["Symptom": "Frailty Symptom"] FrailtySymptom where FrailtySymptom.prevalencePeriod overlaps "Measurement Period" )
"Days Spent in Long Term Care During Measurement Period" > 90
["Encounter, Performed": "Acute Inpatient"] InpatientEncounter where exists ( InpatientEncounter.diagnoses Diagnosis where Diagnosis in "Advanced Illness" ) and InpatientEncounter.relevantPeriod starts 2 years or less before end of "Measurement Period"
( ["Encounter, Performed": "Care Services in Long-Term Residential Facility"] union ["Encounter, Performed": "Nursing Facility Visit"] ) LongTermFacilityEncounter where LongTermFacilityEncounter.relevantPeriod overlaps "Measurement Period" return LongTermFacilityEncounter.relevantPeriod intersect "Measurement Period"
( ["Encounter, Performed": "Outpatient"] union ["Encounter, Performed": "Observation"] union ["Encounter, Performed": "ED"] union ["Encounter, Performed": "Nonacute Inpatient"] ) OutpatientEncounter where exists ( OutpatientEncounter.diagnoses Diagnosis where Diagnosis in "Advanced Illness" ) and OutpatientEncounter.relevantPeriod starts 2 years or less before end of "Measurement Period"
["Diagnosis": "History of bilateral mastectomy"] BilateralMastectomyHistory where BilateralMastectomyHistory.prevalencePeriod starts before end of "Measurement Period"
["Procedure, Performed": "Bilateral Mastectomy"] BilateralMastectomyPerformed where BilateralMastectomyPerformed.relevantPeriod ends before end of "Measurement Period"
"Initial Population"
Hospice."Has Hospice" or ( Count("Unilateral Mastectomy Procedure")= 2 ) or ( ( exists ( "Right Mastectomy Diagnosis" ) or exists ( "Right Mastectomy Procedure" ) ) and ( exists ( "Left Mastectomy Diagnosis" ) or exists ( "Left Mastectomy Procedure" ) ) ) or exists "Bilateral Mastectomy Diagnosis" or exists "Bilateral Mastectomy Procedure" or FrailtyLTI."Advanced Illness and Frailty Exclusion Including Under Age 80" or ( exists ["Patient Characteristic Birthdate": "Birth date"] BirthDate where ( Global."CalendarAgeInYearsAt"(BirthDate.birthDatetime, start of "Measurement Period")>= 65 ) and FrailtyLTI."Has Spent More Than 90 Days in Long Term Care" )
exists ( ["Encounter, Performed": "Encounter Inpatient"] DischargeHospice where ( DischargeHospice.dischargeDisposition as Code ~ "Discharge to home for hospice care (procedure)" or DischargeHospice.dischargeDisposition as Code ~ "Discharge to healthcare facility for hospice care (procedure)" ) and DischargeHospice.relevantPeriod ends during "Measurement Period" ) or exists ( ["Intervention, Order": "Hospice care ambulatory"] HospiceOrder where HospiceOrder.authorDatetime during "Measurement Period" ) or exists ( ["Intervention, Performed": "Hospice care ambulatory"] HospicePerformed where HospicePerformed.relevantPeriod overlaps "Measurement Period" )
exists ( ["Patient Characteristic Sex": "Female"] ) and exists ["Patient Characteristic Birthdate": "Birth date"] BirthDate where Global."CalendarAgeInYearsAt"(BirthDate.birthDatetime, start of "Measurement Period")in Interval[51, 74 ) and exists AdultOutpatientEncounters."Qualifying Encounters"
( ["Diagnosis": "Status Post Left Mastectomy"] union ( ["Diagnosis": "Unilateral Mastectomy, Unspecified Laterality"] UnilateralMastectomyDiagnosis where UnilateralMastectomyDiagnosis.anatomicalLocationSite in "Left" ) ) LeftMastectomy where LeftMastectomy.prevalencePeriod starts before end of "Measurement Period"
["Procedure, Performed": "Unilateral Mastectomy Left"] UnilateralMastectomyLeftPerformed where UnilateralMastectomyLeftPerformed.relevantPeriod ends before end of "Measurement Period"
exists ( ["Diagnostic Study, Performed": "Mammography"] Mammogram where ( Mammogram.relevantPeriod ends 27 months or less before day of end "Measurement Period" ) )
( ["Diagnosis": "Status Post Right Mastectomy"] RightMastectomyProcedure union ( ["Diagnosis": "Unilateral Mastectomy, Unspecified Laterality"] UnilateralMastectomyDiagnosis where UnilateralMastectomyDiagnosis.anatomicalLocationSite in "Right" ) ) RightMastectomy where RightMastectomy.prevalencePeriod starts before end of "Measurement Period"
["Procedure, Performed": "Unilateral Mastectomy Right"] UnilateralMastectomyRightPerformed where UnilateralMastectomyRightPerformed.relevantPeriod ends before end of "Measurement Period"
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
["Procedure, Performed": "Unilateral Mastectomy"] UnilateralMastectomy where UnilateralMastectomy.relevantPeriod ends before end of "Measurement Period"
Sum((collapse Intervals)CollapsedInterval return all duration in days of CollapsedInterval )
years between ToDate(BirthDateTime)and ToDate(AsOf)
DateTime(year from Value, month from Value, day from Value, 0, 0, 0, 0, timezone from Value)
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
Measure Set |