eCQM Title | # Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
eCQM Identifier (Measure Authoring Tool) | 22 | eCQM Version Number | 11.0.000
NQF Number | Not Applicable | GUID | 9a033a94-3d9b-11e1-8634-00237d5bf174
Measurement Period | January 1, 20XX through December 31, 20XX
Measure Steward | Centers for Medicare & Medicaid Services (CMS)
Measure Developer | Mathematica
Endorsed By | None
Description |
    Percentage of patient visits for patients aged 18 years and older seen during the measurement period who were screened for high blood pressure AND a recommended follow-up plan is documented, as indicated, if blood pressure is elevated or hypertensive
Copyright |
    Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets.

    CPT(R) contained in the Measure specifications is copyright 2004-2021 American Medical Association. LOINC(R) is copyright 2004-2021 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2021 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2021 World Health Organization. All Rights Reserved.
Disclaimer |
    These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications.

    THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

    Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].
Measure Scoring | Proportion
Measure Type | Process
Stratification |
    None
Risk Adjustment |
    None
Rate Aggregation |
    None
Rationale |
    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). Prevention of hypertension and the treatment of established hypertension are complementary approaches to reducing CVD risk in the population, but prevention of hypertension provides the optimal means of reducing risk and avoiding harmful consequences. Periodic BP screening can identify individuals who develop elevated BP over time. More frequent BP screening may be particularly important for individuals with elevated ASCVD risk (Whelton PK, et al., 2018).

    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. A review of 35 studies found that the pharmacist-led interventions involved medication counseling and patient education. Twenty-nine of the 35 studies showed statistically significant improvement in BP levels of the intervention groups at follow-up (Reeves et al., 2020). Follow-up intervals based on blood pressure control have been established by the 2017 ACC/AHA guideline and the USPSTF.
Clinical Recommendation Statement |
    The U.S. Preventive Services Task Force (USPSTF) recommends screening for high blood pressure in adults age 18 years and older. This is a grade A recommendation.
Improvement Notation |
    Higher score indicates better quality
Reference |
    Reference Type: CITATION
    Reference Text: 'Appleton, S. L., Neo, C., Hill, C. L., Douglas, K. A., & Adams, R. J. (2013). Untreated hypertension: prevalence and patient factors and beliefs associated with under-treatment in a population sample. Journal of Human Hypertension, 27, 453-462. https://doi.org/10.1038/jhh.2012.62'
Reference |
    Reference Type: CITATION
    Reference Text: 'Garrison, G. M. & Oberhelman, S. (2013). Screening for hypertension annually compared with current practice. Annals of Family Medicine, 11 (2), 116-121. doi:10.1370/afm.1467'
Reference |
    Reference Type: CITATION
    Reference Text: 'Greenland, P., Alpert, J. S., Beller, G. A., Benjamin, E. J., Budoff, M. J., Fayad, Z. A., Foster, E., Hlatky, M. A., Hodgson, J. M., Kushner, F. G., Lauer, M. S., Shaw, L. J., Smith, S. C., Jr, Taylor, A. J., Weintraub, W. S., Wenger, N. K., Jacobs, A. K., Smith, S. C., Jr, Anderson, J. L., Albert, N., … American Heart Association (2010). 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 56(25), e50–e103. https://doi.org/10.1016/j.jacc.2010.09.001'
Reference |
    Reference Type: CITATION
    Reference Text: 'Luehr, D., Woolley, T., Burke, R., Dohmen, F., Hayes, R., Johnson, M...., Schoenleber, M. (2012). Hypertension diagnosis and treatment; Institute for Clinical Systems Improvement health care guideline. Updated November, 2012'
Reference |
    Reference Type: CITATION
    Reference Text: 'Reeves, L., Robinson, K., McClelland, T., Adedoyin, C., Broeseker, A., and Adunlin, G. (2020). “Pharmacist Interventions in the Management of Blood Pressure Control and Adherence to Antihypertensive Medications: A Systematic Review of Randomized Controlled Trials.” Journal of Pharmacy Practice. Available at https://doi.org/10.1177/0897190020903573. Accessed October 5, 2020'
Reference |
    Reference Type: CITATION
    Reference Text: 'U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute & National High Blood Pressure Education Program (2003). The Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7). NIH Publication No. 03-5233'
Reference |
    Reference Type: CITATION
    Reference Text: 'U.S. Preventive Services Task Force (USPSTF) (2007). Screening for high blood pressure: U.S. Preventive Services Task Force reaffirmation recommendation statement. Annals of Internal Medicine; 147(11):783-6'
Reference |
    Reference Type: CITATION
    Reference Text: 'Whelton, P.K., Carey, R.M., Aronow, W.S., Casey, D.E., Collins, K., Dennison Himmelfarb, C., Depalma, S.M., Gidding, S., Jamerson, K.A., Jones, D.W., MacLaughlin, E.J, Muntener, P., Ovbiaggele, B., Smith, S.C., Spencer, C.C., Stafford, R.S., Taler, S.J., Thomas, R.J., Williams, K. A., Williamson, J.D., Wright, J.T., (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension, 71(6), e13-e115. doi.org/10.1161/HYP.0000000000000065'
Reference |
    Reference Type: CITATION
    Reference Text: 'Winter, K. H., Tuttle, L. A. & Viera, A.J. (2013). Hypertension. Primary Care Clinics in Office Practice, 40, 179-194. doi:10.1016/j.pop.2012.11.008'
Definition |
    Blood Pressure (BP) Classification:
    BP is defined by four (4) BP reading classifications: Normal, Elevated, First Hypertensive, and Second Hypertensive Readings
    *Normal BP: Systolic BP (SBP) < 120 mmHg AND Diastolic BP (DBP) < 80 mmHg
    *Elevated BP: SBP of 120-129 mmHg AND DBP < 80 mmHg
    *First Hypertensive Reading: SBP of >= 130 mmHg OR DBP of >= 80 mmHg without a previous SBP of >= 130 mmHg OR DBP of >= 80 mmHg during the 12 months prior to the encounter
    *Second Hypertensive Reading: Requires a SBP >= 130 mmHg OR DBP >= 80 mmHg during the current encounter AND a most recent BP reading within the last 12 months SBP >= 130 mmHg OR DBP >= 80 mmHg

    Recommended BP Follow-Up:
    The 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults from the American College of Cardiology and American Heart Association (2017 Guideline) recommends BP screening thresholds as defined under Blood Pressure Classifications and recommends interventions based on the current BP reading as listed in the "Recommended Blood Pressure Follow-Up Interventions" below.

    The types of Recommended Nonpharmacologic Interventions, such as lifestyle modifications, are listed following the section on Recommended Follow-Up Interventions based on BP Classification.

    Recommended Blood Pressure Follow-Up Interventions:
    *Normal BP: No follow-up required for SBP < 120 mmHg AND DBP < 80 mmHg
    *Elevated BP: Patients with SBP of 120-129 mmHg AND DBP < 80 mmHg:
       *Referral to Alternate/Primary Care Health Care Professional
       OR
       *Follow-up with rescreen in 2 to 6 months AND recommend nonpharmacologic interventions
    *First Hypertensive BP Reading: Patients with one elevated reading of SBP >= 130 mmHg
     OR DBP >= 80 mmHg:
       *Referral to Alternate/Primary Care Health Care Professional
        OR
        *Follow-up with rescreen > 1 day and < 4 weeks AND recommend nonpharmacologic interventions
    *Second Hypertensive BP Reading:
       -Second Hypertensive BP Reading: Patients with second elevated reading of
               SBP of 130-139 mmHg OR DBP of 80-89 mmHg (and not SBP >=140 OR DBP >=90):
              *Referral to Alternate/Primary Care Healthcare Professional
               OR
              *Nonpharmacologic intervention AND reassessment in 2-6 months
                 AND an order for a laboratory test or ECG for hypertension
       -Second Hypertensive BP Reading: SBP>=140 or DBP>=90:
              *Referral to Alternate/Primary Care Healthcare Professional
               OR
              *Nonpharmacologic intervention AND BP-lowering medication
               AND reassessment within 4 weeks AND an order for a laboratory test or ECG for hypertension

    The 2017 Guideline outlines nonpharmacologic interventions (lifestyle modifications) which must include one or more of the following as indicated:
    *Weight Reduction
    *Dietary Approaches to Stop Hypertension (DASH) Eating Plan
    *Dietary Sodium Restriction
    *Increased Physical Activity
    *Moderation in alcohol (ETOH)
Guidance |
    This eCQM is an episode-based measure. An episode is defined as each eligible encounter for patients aged 18 years and older during the measurement period. This measure should be reported for every visit. The measure requires that blood pressure measurements (i.e., diastolic and systolic) be obtained during each visit in order to determine the blood pressure reading used to evaluate if an intervention is needed.

    Both the systolic and diastolic blood pressure measurements are required for inclusion. If there are multiple blood pressures obtained during a patient visit, only the last, or most recent, pressure measurement will be used to evaluate the measure requirements.

    The intent of this measure is to screen patients for high blood pressure and provide recommended follow-up as indicated. The documented follow-up plan must be related to the current blood pressure reading as indicated, example: "Patient referred to primary care provider for BP management."

    Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth.

    This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.
Transmission Format |
    TBD
Initial Population |
    All patient visits for patients aged 18 years and older at the beginning of the measurement period
Denominator |
    Equals Initial Population
Denominator Exclusions |
    Patient has an active diagnosis of hypertension
Numerator |
    Patient visits where patients were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated, if the blood pressure is elevated or hypertensive
Numerator Exclusions |
    Not Applicable
Denominator Exceptions |
    Documentation of medical reason(s) for not screening for high blood pressure (e.g., patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient's health status).

    Documentation of patient reason(s) for not screening for blood pressure measurements or for not ordering an appropriate follow-up intervention if patient BP is elevated or hypertensive (e.g., patient refuses).
Supplemental Data Elements |
    For every patient evaluated by this measure also identify payer, race, ethnicity and sex

## Table of Contents

- Population Criteria
- Definitions
- Functions
- Terminology
- Data Criteria (QDM Data Elements)
- Supplemental Data Elements
- Risk Adjustment Variables

### Population Criteria

- - Initial Population

    - -     "Qualifying Encounter during Measurement Period" QualifyingEncounter
              where AgeInYearsAt(date from start of "Measurement Period")>= 18

- - Denominator

    - -     "Initial Population"

- - Denominator Exclusions

    - -     "Qualifying Encounter during Measurement Period" QualifyingEncounter
              with ["Diagnosis": "Diagnosis of Hypertension"] Hypertension
                such that Hypertension.prevalencePeriod overlaps before QualifyingEncounter.relevantPeriod

- - Numerator

    - -     "Encounter with Normal Blood Pressure Reading"
              union ( "Encounter with Elevated Blood Pressure Reading SBP 120 to 129 AND DBP less than 80 and Interventions" )
              union ( "Encounter with First Hypertensive Reading SBP Greater than or Equal to 130 OR DBP Greater than or Equal to 80 and Interventions" )
              union ( "Encounter with Second Hypertensive Reading SBP 130 to 139 OR DBP 80 to 89 and Interventions" )
              union ( "Encounter with Second Hypertensive Reading SBP Greater than or Equal to 140 OR DBP Greater than or Equal to 90 and Interventions" )

- - Numerator Exclusions

    - -     None

- - Denominator Exceptions

    - -     "Encounter with Medical Reason for Not Obtaining or Patient Declined Blood Pressure Measurement"
              union "Encounter with Order for Hypertension Follow Up Declined by Patient"

- - Stratification

    - -     None

### Definitions

- - Denominator

    - -     "Initial Population"

  - Denominator Exceptions

    - -     "Encounter with Medical Reason for Not Obtaining or Patient Declined Blood Pressure Measurement"
              union "Encounter with Order for Hypertension Follow Up Declined by Patient"

  - Denominator Exclusions

    - -     "Qualifying Encounter during Measurement Period" QualifyingEncounter
              with ["Diagnosis": "Diagnosis of Hypertension"] Hypertension
                such that Hypertension.prevalencePeriod overlaps before QualifyingEncounter.relevantPeriod

  - Encounter with Elevated Blood Pressure Reading SBP 120 to 129 AND DBP less than 80

    - -     "Qualifying Encounter during Measurement Period" QualifyingEncounter
              let EncounterLastSystolicBP: Last(["Physical Exam, Performed": "Systolic blood pressure"] SystolicBP
                  where Global."NormalizeInterval"(SystolicBP.relevantDatetime, SystolicBP.relevantPeriod)ends during QualifyingEncounter.relevantPeriod
                  sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)
              ),
              EncounterLastDiastolicBP: Last(["Physical Exam, Performed": "Diastolic blood pressure"] DiastolicBP
                  where Global."NormalizeInterval"(DiastolicBP.relevantDatetime, DiastolicBP.relevantPeriod)ends during QualifyingEncounter.relevantPeriod
                  sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)
              )
              where ( EncounterLastSystolicBP.result included in Interval[120 'mm[Hg]', 129 'mm[Hg]']
                  and EncounterLastDiastolicBP.result included in Interval[1 'mm[Hg]', 80 'mm[Hg]' )
              )

  - Encounter with Elevated Blood Pressure Reading SBP 120 to 129 AND DBP less than 80 and Interventions

    - -     ( "Encounter with Elevated Blood Pressure Reading SBP 120 to 129 AND DBP less than 80" ElevatedEncounter
                with "Follow up with Rescreen in 2 to 6 Months" Twoto6MonthRescreen
                  such that Twoto6MonthRescreen.authorDatetime same day as start of ElevatedEncounter.relevantPeriod
                with "NonPharmacological Interventions" NonPharmInterventions
                  such that NonPharmInterventions.authorDatetime same day as start of ElevatedEncounter.relevantPeriod
            )
              union ( "Encounter with Elevated Blood Pressure Reading SBP 120 to 129 AND DBP less than 80" ElevatedEncounter
                  with "Referral to Alternate or Primary Healthcare Professional for Hypertensive Reading" Referral
                    such that Referral.authorDatetime same day as start of ElevatedEncounter.relevantPeriod
              )

  - Encounter with First Hypertensive Reading SBP Greater than or Equal to 130 OR DBP Greater than or Equal to 80

    - -     ( "Qualifying Encounter during Measurement Period" QualifyingEncounter
                let EncounterLastSystolicBP: Last(["Physical Exam, Performed": "Systolic blood pressure"] SystolicBP
                    where Global."NormalizeInterval"(SystolicBP.relevantDatetime, SystolicBP.relevantPeriod)ends during QualifyingEncounter.relevantPeriod
                    sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)
                ),
                EncounterLastDiastolicBP: Last(["Physical Exam, Performed": "Diastolic blood pressure"] DiastolicBP
                    where Global."NormalizeInterval"(DiastolicBP.relevantDatetime, DiastolicBP.relevantPeriod)ends during QualifyingEncounter.relevantPeriod
                    sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)
                )
                where EncounterLastSystolicBP.result > 0 'mm[Hg]'
                  and EncounterLastDiastolicBP.result > 0 'mm[Hg]'
                  and ( EncounterLastSystolicBP.result >= 130 'mm[Hg]'
                      or EncounterLastDiastolicBP.result >= 80 'mm[Hg]'
                  )
            )
              except "Encounter with Hypertensive Reading Within Year Prior"

  - Encounter with First Hypertensive Reading SBP Greater than or Equal to 130 OR DBP Greater than or Equal to 80 and Interventions

    - -     "Encounter with First Hypertensive Reading SBP Greater than or Equal to 130 OR DBP Greater than or Equal to 80" FirstHTNEncounter
              with "First Hypertensive Reading Interventions or Referral to Alternate Professional" FirstHTNIntervention
                such that FirstHTNIntervention.authorDatetime same day as start of FirstHTNEncounter.relevantPeriod

  - Encounter with Hypertensive Reading Within Year Prior

    - -     "Qualifying Encounter during Measurement Period" QualifyingEncounter
              let EncounterLastSystolicBP: Last(["Physical Exam, Performed": "Systolic blood pressure"] SystolicBP
                  where Global."NormalizeInterval"(SystolicBP.relevantDatetime, SystolicBP.relevantPeriod)ends 1 year or less before start of QualifyingEncounter.relevantPeriod
                  sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)
              ),
              EncounterLastDiastolicBP: Last(["Physical Exam, Performed": "Diastolic blood pressure"] DiastolicBP
                  where Global."NormalizeInterval"(DiastolicBP.relevantDatetime, DiastolicBP.relevantPeriod)ends 1 year or less before start of QualifyingEncounter.relevantPeriod
                  sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)
              )
              where EncounterLastSystolicBP.result > 0 'mm[Hg]'
                and EncounterLastDiastolicBP.result > 0 'mm[Hg]'
                and ( EncounterLastSystolicBP.result >= 130 'mm[Hg]'
                    or EncounterLastDiastolicBP.result >= 80 'mm[Hg]'
                )

  - Encounter with Medical Reason for Not Obtaining or Patient Declined Blood Pressure Measurement

    - -     "Qualifying Encounter during Measurement Period" QualifyingEncounter
              with ( ["Physical Exam, Not Performed": "Systolic blood pressure"]
                union ["Physical Exam, Not Performed": "Diastolic blood pressure"] ) NoBPScreen
                such that ( NoBPScreen.negationRationale in "Medical Reason"
                    or NoBPScreen.negationRationale in "Patient Declined"
                )
                  and NoBPScreen.authorDatetime same day as start of QualifyingEncounter.relevantPeriod

  - Encounter with Normal Blood Pressure Reading

    - -     "Qualifying Encounter during Measurement Period" QualifyingEncounter
              let EncounterLastSystolicBP: Last(["Physical Exam, Performed": "Systolic blood pressure"] SystolicBP
                  where Global."NormalizeInterval"(SystolicBP.relevantDatetime, SystolicBP.relevantPeriod)ends during QualifyingEncounter.relevantPeriod
                  sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)
              ),
              EncounterLastDiastolicBP: Last(["Physical Exam, Performed": "Diastolic blood pressure"] DiastolicBP
                  where Global."NormalizeInterval"(DiastolicBP.relevantDatetime, DiastolicBP.relevantPeriod)ends during QualifyingEncounter.relevantPeriod
                  sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)
              )
              where EncounterLastSystolicBP.result included in Interval[1 'mm[Hg]', 120 'mm[Hg]' )
                and EncounterLastDiastolicBP.result included in Interval[1 'mm[Hg]', 80 'mm[Hg]' )

  - Encounter with Order for Hypertension Follow Up Declined by Patient

    - -     ( "Encounter with Elevated Blood Pressure Reading SBP 120 to 129 AND DBP less than 80" ElevatedBPEncounter
                with ( "NonPharmacological Intervention Not Ordered"
                  union ["Intervention, Not Ordered": "Referral to Primary Care or Alternate Provider"]
                  union ["Intervention, Not Ordered": "Follow-up 2-3 months (finding)"]
                  union ["Intervention, Not Ordered": "Follow-up 4-6 months (finding)"] ) ElevatedBPDeclinedInterventions
                  such that ElevatedBPDeclinedInterventions.negationRationale in "Patient Declined"
                    and ElevatedBPDeclinedInterventions.authorDatetime same day as start of ElevatedBPEncounter.relevantPeriod
            )
              union ( "Encounter with First Hypertensive Reading SBP Greater than or Equal to 130 OR DBP Greater than or Equal to 80" FirstHTNEncounter
                  with ( "NonPharmacological Intervention Not Ordered"
                    union ["Intervention, Not Ordered": "Follow Up Within 4 Weeks"]
                    union ["Intervention, Not Ordered": "Referral to Primary Care or Alternate Provider"] ) FirstHTNDeclinedInterventions
                    such that FirstHTNDeclinedInterventions.negationRationale in "Patient Declined"
                      and FirstHTNDeclinedInterventions.authorDatetime same day as start of FirstHTNEncounter.relevantPeriod
              )
              union ( "Encounter with Second Hypertensive Reading SBP 130 to 139 OR DBP 80 to 89" SecondHTNEncounter
                  with "Second Hypertensive Reading SBP 130 to 139 OR DBP 80 to 89 Interventions Declined" SecondHTNDeclinedInterventions
                    such that SecondHTNDeclinedInterventions.authorDatetime same day as start of SecondHTNEncounter.relevantPeriod
              )
              union ( "Encounter with Second Hypertensive Reading SBP Greater than or Equal to 140 OR DBP Greater than or Equal to 90" SecondHTN140Over90Encounter
                  with "Second Hypertensive Reading SBP Greater than or Equal to 140 OR DBP Greater than or Equal to 90 Interventions Declined" SecondHTN140Over90DeclinedInterventions
                    such that SecondHTN140Over90DeclinedInterventions.authorDatetime same day as start of SecondHTN140Over90Encounter.relevantPeriod
              )

  - Encounter with Second Hypertensive Reading SBP 130 to 139 OR DBP 80 to 89

    - -     ( "Qualifying Encounter during Measurement Period" QualifyingEncounter
                let EncounterLastSystolicBP: Last(["Physical Exam, Performed": "Systolic blood pressure"] SystolicBP
                    where Global."NormalizeInterval"(SystolicBP.relevantDatetime, SystolicBP.relevantPeriod)ends during QualifyingEncounter.relevantPeriod
                    sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)
                ),
                EncounterLastDiastolicBP: Last(["Physical Exam, Performed": "Diastolic blood pressure"] DiastolicBP
                    where Global."NormalizeInterval"(DiastolicBP.relevantDatetime, DiastolicBP.relevantPeriod)ends during QualifyingEncounter.relevantPeriod
                    sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)
                )
                where ( EncounterLastSystolicBP.result in Interval[130 'mm[Hg]', 139 'mm[Hg]']
                    or EncounterLastDiastolicBP.result in Interval[80 'mm[Hg]', 89 'mm[Hg]']
                )
                  and not ( EncounterLastSystolicBP.result >= 140 'mm[Hg]'
                      or EncounterLastDiastolicBP.result >= 90 'mm[Hg]'
                  )
            )
              intersect "Encounter with Hypertensive Reading Within Year Prior"

  - Encounter with Second Hypertensive Reading SBP 130 to 139 OR DBP 80 to 89 and Interventions

    - -     ( "Encounter with Second Hypertensive Reading SBP 130 to 139 OR DBP 80 to 89" SecondHTNEncounterReading
                with "Second Hypertensive Reading SBP 130 to 139 OR DBP 80 to 89 and Interventions" EncounterInterventions
                  such that EncounterInterventions.authorDatetime same day as start of SecondHTNEncounterReading.relevantPeriod
            )
              union ( "Encounter with Second Hypertensive Reading SBP 130 to 139 OR DBP 80 to 89" SecondHTNEncounterReading
                  with "Referral to Alternate or Primary Healthcare Professional for Hypertensive Reading" ReferralForHTN
                    such that ReferralForHTN.authorDatetime same day as start of SecondHTNEncounterReading.relevantPeriod
              )

  - Encounter with Second Hypertensive Reading SBP Greater than or Equal to 140 OR DBP Greater than or Equal to 90

    - -     ( ( "Qualifying Encounter during Measurement Period" QualifyingEncounter
                  let EncounterLastSystolicBP: Last(["Physical Exam, Performed": "Systolic blood pressure"] SystolicBP
                      where Global."NormalizeInterval"(SystolicBP.relevantDatetime, SystolicBP.relevantPeriod)ends during QualifyingEncounter.relevantPeriod
                      sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)
                  ),
                  EncounterLastDiastolicBP: Last(["Physical Exam, Performed": "Diastolic blood pressure"] DiastolicBP
                      where Global."NormalizeInterval"(DiastolicBP.relevantDatetime, DiastolicBP.relevantPeriod)ends during QualifyingEncounter.relevantPeriod
                      sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)
                  )
                  where EncounterLastSystolicBP.result > 0 'mm[Hg]'
                    and EncounterLastDiastolicBP.result > 0 'mm[Hg]'
                    and ( EncounterLastSystolicBP.result >= 140 'mm[Hg]'
                        or EncounterLastDiastolicBP.result >= 90 'mm[Hg]'
                    )
              )
                intersect "Encounter with Hypertensive Reading Within Year Prior"
            )

  - Encounter with Second Hypertensive Reading SBP Greater than or Equal to 140 OR DBP Greater than or Equal to 90 and Interventions

    - -     ( "Encounter with Second Hypertensive Reading SBP Greater than or Equal to 140 OR DBP Greater than or Equal to 90" SecondHTNEncounterReading140Over90
                with "Second Hypertensive Reading SBP Greater than or Equal to 140 OR DBP Greater than or Equal to 90 Interventions" SecondHTN140Over90Interventions
                  such that SecondHTN140Over90Interventions.authorDatetime same day as start of SecondHTNEncounterReading140Over90.relevantPeriod
            )
              union "Encounter with Second Hypertensive Reading SBP Greater than or Equal to 140 OR DBP Greater than or Equal to 90" SecondHTNEncounterReading140Over90
                with "Referral to Alternate or Primary Healthcare Professional for Hypertensive Reading" ReferralToProfessional
                  such that ReferralToProfessional.authorDatetime same day as start of SecondHTNEncounterReading140Over90.relevantPeriod

  - First Hypertensive Reading Interventions or Referral to Alternate Professional

    - -     ( ["Intervention, Order": "Follow Up Within 4 Weeks"] FourWeekRescreen
                with "NonPharmacological Interventions" NonPharmInterventionsHTN
                  such that FourWeekRescreen.authorDatetime same day as NonPharmInterventionsHTN.authorDatetime
            )
              union ( "Referral to Alternate or Primary Healthcare Professional for Hypertensive Reading" )

  - Follow up with Rescreen in 2 to 6 Months

    - -     ( ["Intervention, Order": "Follow-up 2-3 months (finding)"]
                union ["Intervention, Order": "Follow-up 4-6 months (finding)"]
            )

  - Initial Population

    - -     "Qualifying Encounter during Measurement Period" QualifyingEncounter
              where AgeInYearsAt(date from start of "Measurement Period")>= 18

  - Laboratory Test or ECG for Hypertension

    - -     ( ["Diagnostic Study, Order": "EKG 12 channel panel"]
                union ["Diagnostic Study, Order": "EKG study"]
                union ["Laboratory Test, Order": "Laboratory Tests for Hypertension"]
            )

  - Laboratory Test or ECG for Hypertension Not Ordered

    - -     ( ["Diagnostic Study, Not Ordered": "EKG 12 channel panel"]
                union ["Diagnostic Study, Not Ordered": "EKG study"]
                union ["Laboratory Test, Not Ordered": "Laboratory Tests for Hypertension"]
            )

  - NonPharmacological Intervention Not Ordered

    - -     ( ["Intervention, Not Ordered": "Lifestyle Recommendation"]
                union ["Intervention, Not Ordered": "Weight Reduction Recommended"]
                union ["Intervention, Not Ordered": "Dietary Recommendations"]
                union ["Intervention, Not Ordered": "Recommendation to Increase Physical Activity"]
                union ["Intervention, Not Ordered": "Referral or Counseling for Alcohol Consumption"]
            )

  - NonPharmacological Interventions

    - -     ( ["Intervention, Order": "Lifestyle Recommendation"]
                union ["Intervention, Order": "Weight Reduction Recommended"]
                union ["Intervention, Order": "Dietary Recommendations"]
                union ["Intervention, Order": "Recommendation to Increase Physical Activity"]
                union ["Intervention, Order": "Referral or Counseling for Alcohol Consumption"]
            )

  - Numerator

    - -     "Encounter with Normal Blood Pressure Reading"
              union ( "Encounter with Elevated Blood Pressure Reading SBP 120 to 129 AND DBP less than 80 and Interventions" )
              union ( "Encounter with First Hypertensive Reading SBP Greater than or Equal to 130 OR DBP Greater than or Equal to 80 and Interventions" )
              union ( "Encounter with Second Hypertensive Reading SBP 130 to 139 OR DBP 80 to 89 and Interventions" )
              union ( "Encounter with Second Hypertensive Reading SBP Greater than or Equal to 140 OR DBP Greater than or Equal to 90 and Interventions" )

  - Qualifying Encounter during Measurement Period

    - -     ["Encounter, Performed": "Encounter to Screen for Blood Pressure"] ValidEncounter
              where ValidEncounter.relevantPeriod during "Measurement Period"
                and ValidEncounter.class !~ "virtual"

  - Referral to Alternate or Primary Healthcare Professional for Hypertensive Reading

    - -     ["Intervention, Order": "Referral to Primary Care or Alternate Provider"] Referral
              where Referral.reason in "Finding of Elevated Blood Pressure or Hypertension"

  - SDE Ethnicity

    - -     ["Patient Characteristic Ethnicity": "Ethnicity"]

  - SDE Payer

    - -     ["Patient Characteristic Payer": "Payer"]

  - SDE Race

    - -     ["Patient Characteristic Race": "Race"]

  - SDE Sex

    - -     ["Patient Characteristic Sex": "ONC Administrative Sex"]

  - Second Hypertensive Reading SBP 130 to 139 OR DBP 80 to 89 and Interventions

    - -     ( "Follow up with Rescreen in 2 to 6 Months" Rescreen2to6
              with "Laboratory Test or ECG for Hypertension" LabECGIntervention
                such that Rescreen2to6.authorDatetime same day as LabECGIntervention.authorDatetime ) RescreenLabECG
              with "NonPharmacological Interventions" NonPharmSecondIntervention
                such that RescreenLabECG.authorDatetime same day as NonPharmSecondIntervention.authorDatetime

  - Second Hypertensive Reading SBP 130 to 139 OR DBP 80 to 89 Interventions Declined

    - -     ( ["Intervention, Not Ordered": "Referral to Primary Care or Alternate Provider"]
              union "Laboratory Test or ECG for Hypertension Not Ordered"
              union ["Intervention, Not Ordered": "Follow-up 2-3 months (finding)"]
              union ["Intervention, Not Ordered": "Follow-up 4-6 months (finding)"]
              union "NonPharmacological Intervention Not Ordered" ) SecondHTNDeclinedInterventions
              where SecondHTNDeclinedInterventions.negationRationale in "Patient Declined"

  - Second Hypertensive Reading SBP Greater than or Equal to 140 OR DBP Greater than or Equal to 90 Interventions

    - -     ( ( ( ["Intervention, Order": "Follow Up Within 4 Weeks"] WeeksRescreen
                with "Laboratory Test or ECG for Hypertension" ECGLabTest
                  such that WeeksRescreen.authorDatetime same day as ECGLabTest.authorDatetime ) RescreenECGLab
                with "NonPharmacological Interventions" HTNInterventions
                  such that HTNInterventions.authorDatetime same day as RescreenECGLab.authorDatetime ) RescreenECGLabInterventions
                with ["Medication, Order": "Pharmacologic Therapy for Hypertension"] Medications
                  such that Medications.authorDatetime same day as RescreenECGLabInterventions.authorDatetime
            )

  - Second Hypertensive Reading SBP Greater than or Equal to 140 OR DBP Greater than or Equal to 90 Interventions Declined

    - -     ( ["Intervention, Not Ordered": "Referral to Primary Care or Alternate Provider"]
              union ["Medication, Not Ordered": "Pharmacologic Therapy for Hypertension"]
              union "Laboratory Test or ECG for Hypertension Not Ordered"
              union ["Intervention, Not Ordered": "Follow Up Within 4 Weeks"]
              union "NonPharmacological Intervention Not Ordered" ) SecondHTN140Over90InterventionsNotOrdered
              where SecondHTN140Over90InterventionsNotOrdered.negationRationale in "Patient Declined"

### Functions

- - Global.NormalizeInterval(pointInTime DateTime, period Interval<DateTime>)

    - -     if pointInTime is not null then Interval[pointInTime, pointInTime]
              else if period is not null then period
              else null as Interval<DateTime>

### Terminology

- code "Diastolic blood pressure" ("LOINC Code (8462-4)")
- code "EKG 12 channel panel" ("LOINC Code (34534-8)")
- code "EKG study" ("LOINC Code (11524-6)")
- code "Follow-up 2-3 months (finding)" ("SNOMEDCT Code (183624006)")
- code "Follow-up 4-6 months (finding)" ("SNOMEDCT Code (183625007)")
- code "Systolic blood pressure" ("LOINC Code (8480-6)")
- code "virtual" ("ActCode Code (VR)")
- valueset "Diagnosis of Hypertension" (2.16.840.1.113883.3.600.263)
- valueset "Dietary Recommendations" (2.16.840.1.113883.3.600.1515)
- valueset "Encounter to Screen for Blood Pressure" (2.16.840.1.113883.3.600.1920)
- valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
- valueset "Finding of Elevated Blood Pressure or Hypertension" (2.16.840.1.113762.1.4.1047.514)
- valueset "Follow Up Within 4 Weeks" (2.16.840.1.113883.3.526.3.1578)
- valueset "Laboratory Tests for Hypertension" (2.16.840.1.113883.3.600.1482)
- valueset "Lifestyle Recommendation" (2.16.840.1.113883.3.526.3.1581)
- valueset "Medical Reason" (2.16.840.1.113883.3.526.3.1007)
- valueset "ONC Administrative Sex" (2.16.840.1.113762.1.4.1)
- valueset "Patient Declined" (2.16.840.1.113883.3.526.3.1582)
- valueset "Payer" (2.16.840.1.114222.4.11.3591)
- valueset "Pharmacologic Therapy for Hypertension" (2.16.840.1.113883.3.526.1577)
- valueset "Race" (2.16.840.1.114222.4.11.836)
- valueset "Recommendation to Increase Physical Activity" (2.16.840.1.113883.3.600.1518)
- valueset "Referral or Counseling for Alcohol Consumption" (2.16.840.1.113883.3.526.3.1583)
- valueset "Referral to Primary Care or Alternate Provider" (2.16.840.1.113883.3.526.3.1580)
- valueset "Weight Reduction Recommended" (2.16.840.1.113883.3.600.1510)

### Data Criteria (QDM Data Elements)

- "Diagnosis: Diagnosis of Hypertension" using "Diagnosis of Hypertension (2.16.840.1.113883.3.600.263)"
- "Diagnostic Study, Not Ordered: EKG 12 channel panel" using "EKG 12 channel panel (LOINC Code 34534-8)"
- "Diagnostic Study, Not Ordered: EKG study" using "EKG study (LOINC Code 11524-6)"
- "Diagnostic Study, Order: EKG 12 channel panel" using "EKG 12 channel panel (LOINC Code 34534-8)"
- "Diagnostic Study, Order: EKG study" using "EKG study (LOINC Code 11524-6)"
- "Encounter, Performed: Encounter to Screen for Blood Pressure" using "Encounter to Screen for Blood Pressure (2.16.840.1.113883.3.600.1920)"
- "Intervention, Not Ordered: Dietary Recommendations" using "Dietary Recommendations (2.16.840.1.113883.3.600.1515)"
- "Intervention, Not Ordered: Follow Up Within 4 Weeks" using "Follow Up Within 4 Weeks (2.16.840.1.113883.3.526.3.1578)"
- "Intervention, Not Ordered: Follow-up 2-3 months (finding)" using "Follow-up 2-3 months (finding) (SNOMEDCT Code 183624006)"
- "Intervention, Not Ordered: Follow-up 4-6 months (finding)" using "Follow-up 4-6 months (finding) (SNOMEDCT Code 183625007)"
- "Intervention, Not Ordered: Lifestyle Recommendation" using "Lifestyle Recommendation (2.16.840.1.113883.3.526.3.1581)"
- "Intervention, Not Ordered: Recommendation to Increase Physical Activity" using "Recommendation to Increase Physical Activity (2.16.840.1.113883.3.600.1518)"
- "Intervention, Not Ordered: Referral or Counseling for Alcohol Consumption" using "Referral or Counseling for Alcohol Consumption (2.16.840.1.113883.3.526.3.1583)"
- "Intervention, Not Ordered: Referral to Primary Care or Alternate Provider" using "Referral to Primary Care or Alternate Provider (2.16.840.1.113883.3.526.3.1580)"
- "Intervention, Not Ordered: Weight Reduction Recommended" using "Weight Reduction Recommended (2.16.840.1.113883.3.600.1510)"
- "Intervention, Order: Dietary Recommendations" using "Dietary Recommendations (2.16.840.1.113883.3.600.1515)"
- "Intervention, Order: Follow Up Within 4 Weeks" using "Follow Up Within 4 Weeks (2.16.840.1.113883.3.526.3.1578)"
- "Intervention, Order: Follow-up 2-3 months (finding)" using "Follow-up 2-3 months (finding) (SNOMEDCT Code 183624006)"
- "Intervention, Order: Follow-up 4-6 months (finding)" using "Follow-up 4-6 months (finding) (SNOMEDCT Code 183625007)"
- "Intervention, Order: Lifestyle Recommendation" using "Lifestyle Recommendation (2.16.840.1.113883.3.526.3.1581)"
- "Intervention, Order: Recommendation to Increase Physical Activity" using "Recommendation to Increase Physical Activity (2.16.840.1.113883.3.600.1518)"
- "Intervention, Order: Referral or Counseling for Alcohol Consumption" using "Referral or Counseling for Alcohol Consumption (2.16.840.1.113883.3.526.3.1583)"
- "Intervention, Order: Referral to Primary Care or Alternate Provider" using "Referral to Primary Care or Alternate Provider (2.16.840.1.113883.3.526.3.1580)"
- "Intervention, Order: Weight Reduction Recommended" using "Weight Reduction Recommended (2.16.840.1.113883.3.600.1510)"
- "Laboratory Test, Not Ordered: Laboratory Tests for Hypertension" using "Laboratory Tests for Hypertension (2.16.840.1.113883.3.600.1482)"
- "Laboratory Test, Order: Laboratory Tests for Hypertension" using "Laboratory Tests for Hypertension (2.16.840.1.113883.3.600.1482)"
- "Medication, Not Ordered: Pharmacologic Therapy for Hypertension" using "Pharmacologic Therapy for Hypertension (2.16.840.1.113883.3.526.1577)"
- "Medication, Order: Pharmacologic Therapy for Hypertension" using "Pharmacologic Therapy for Hypertension (2.16.840.1.113883.3.526.1577)"
- "Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)"
- "Patient Characteristic Payer: Payer" using "Payer (2.16.840.1.114222.4.11.3591)"
- "Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)"
- "Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"
- "Physical Exam, Not Performed: Diastolic blood pressure" using "Diastolic blood pressure (LOINC Code 8462-4)"
- "Physical Exam, Not Performed: Systolic blood pressure" using "Systolic blood pressure (LOINC Code 8480-6)"
- "Physical Exam, Performed: Diastolic blood pressure" using "Diastolic blood pressure (LOINC Code 8462-4)"
- "Physical Exam, Performed: Systolic blood pressure" using "Systolic blood pressure (LOINC Code 8480-6)"

### Supplemental Data Elements

- SDE Ethnicity

  - -     ["Patient Characteristic Ethnicity": "Ethnicity"]

- SDE Payer

  - -     ["Patient Characteristic Payer": "Payer"]

- SDE Race

  - -     ["Patient Characteristic Race": "Race"]

- SDE Sex

  - -     ["Patient Characteristic Sex": "ONC Administrative Sex"]

### Risk Adjustment Variables

- None

Measure Set |
    Preventive Care and Screening