Pneumococcal Vaccination Status for Older Adults
| Measure Information | 2023 Performance Period |
|---|---|
| CMS eCQM ID | CMS127v11 |
| NQF Number | Not Applicable |
| MIPS Quality ID | 111 |
| Description |
Percentage of patients 66 years of age and older who have received a pneumococcal vaccine |
| Initial Population |
Patients 66 years of age and older at the start of the measurement period with a visit during the measurement period |
| Numerator |
Patients who received a pneumococcal vaccination on or after their 60th birthday and before the end of the measurement period |
| Numerator Exclusions |
Not Applicable |
| Denominator |
Equals Initial Population |
| Denominator Exclusions |
Exclude patients who are in hospice care for any part of the measurement period |
| Denominator Exceptions |
None |
| Steward | National Committee for Quality Assurance |
| Measure Scoring | Proportion measure |
| Measure Type | Process measure |
| Improvement Notation |
Higher score indicates better quality |
| Guidance |
This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
| Telehealth Eligible | Yes |
| Notes |
*There is a known issue on CMS127v11. See issue EKI-15 on the ONC eCQM Known Issues Dashboard for details. |
| Next Version | No Version Available |
| Previous Version |
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Strikethrough text highlighted in red indicates information changed from the previous version. Text highlighted in green indicates information updated in the new eCQM version.
| Measure Information | 2021 Performance Period | 2022 Performance Period | 2023 Performance Period |
|---|---|---|---|
| Title | Pneumococcal Vaccination Status for Older Adults | Pneumococcal Vaccination Status for Older Adults | Pneumococcal Vaccination Status for Older Adults |
| CMS eCQM ID | CMS127v9 | CMS127v10 | CMS127v11 |
| NQF Number | Not Applicable | Not Applicable | Not Applicable |
| Description |
Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine |
Percentage of patients 66 years of age and older who have ever received a pneumococcal vaccine |
Percentage of patients 66 years of age and older who have received a pneumococcal vaccine |
| Initial Population |
Patients 65 years of age and older with a visit during the measurement period |
Patients 66 years of age and older with a visit during the measurement period |
Patients 66 years of age and older at the start of the measurement period with a visit during the measurement period |
| Denominator |
Equals Initial Population |
Equals Initial Population |
Equals Initial Population |
| Denominator Exclusions | Exclude patients whose hospice care overlaps the measurement period | Exclude patients who are in hospice care for any part of the measurement period. | Exclude patients who are in hospice care for any part of the measurement period |
| Numerator |
Patients who have ever received a pneumococcal vaccination before the end of the measurement period |
Patients who received a pneumococcal vaccination on or after their 60th birthday and before the end of the measurement period; or ever had an adverse reaction to the vaccine before the end of the measurement period |
Patients who received a pneumococcal vaccination on or after their 60th birthday and before the end of the measurement period |
| Numerator Exclusions |
Not Applicable |
Not Applicable |
Not Applicable |
| Denominator Exceptions |
None |
None |
None |
| Measure Steward | National Committee for Quality Assurance | National Committee for Quality Assurance | National Committee for Quality Assurance |
| Measure Scoring | Proportion measure | Proportion measure | Proportion measure |
| Measure Type | Process measure | Process measure | Process measure |
| Improvement Notation |
Higher score indicates better quality |
Higher score indicates better quality |
Higher score indicates better quality |
| Guidance |
Patient self-report for procedures as well as immunization s should be recorded in 'Procedure, Performed' template or 'Immunization, Administered' template in QRDA-1. ACIP (Kobayashi, 2015) provides guidance about the proper interval and relative timing for the administration of two pneumococcal vaccines; this measure assesses whether patients have received at least one of either vaccine. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM. |
Patient self-report for procedures as well as immunizations should be recorded in 'Procedure, Performed' template or 'Immunization, Administered' template in QRDA-1. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM. |
This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
| MIPS Quality ID | 111 | 111 | 111 |
| Telehealth Eligible | Yes | Yes | Yes |
| Next Version | CMS127v10 | CMS127v11 | No Version Available |
| Previous Version | No Version Available | ||
| Notes |
*There is a known issue on CMS127v10. See issue EKI-14 on the ONC eCQM Known Issues Dashboard for details. |
*There is a known issue on CMS127v11. See issue EKI-15 on the ONC eCQM Known Issues Dashboard for details. |
*There is a known issue on CMS127v11. See issue EKI-15 on the ONC eCQM Known Issues Dashboard for details.
Data Element Repository
Header
Revised the measure description to align with the timing intent of when the patient received the vaccination.
Measure Section: Description
Source of Change: Measure Lead
Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
Updated the clinical recommendation statement based on most recent published Advisory Committee on Immunization Practices (ACIP) guidelines.
Measure Section: Clinical Recommendation Statement
Source of Change: ONC Project Tracking System (JIRA): CQM-5153
Updated references.
Measure Section: Reference
Source of Change: Measure Lead
Removed references to QRDA I guidance to avoid duplicating information provided in the CMS QRDA I Implementation Guide.
Measure Section: Guidance
Source of Change: Measure Lead
Updated version number of the Quality Data Model (QDM) used in the measure specification to v5.6.
Measure Section: Guidance
Source of Change: Standards/Technical Update
Added age anchor specification to the initial population statement to clarify measure requirements.
Measure Section: Initial Population
Source of Change: Measure Lead
Removed language related to adverse reactions to align with the measure intent.
Measure Section: Numerator
Source of Change: Measure Lead
Updated grammar and punctuation to improve readability.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Logic
Updated the logic to add the 'NormalizeInterval' function to additional QDM datatypes to decrease implementation burden due to variable use of timing attributes.
Measure Section: Definitions
Source of Change: Measure Lead
Added QDM datatypes 'Encounter, Performed' and 'Assessment, Performed' and associated logic to the Hospice.'Has Hospice Services' definition to provide additional approaches for identifying patients receiving hospice services.
Measure Section: Definitions
Source of Change: Measure Lead
Updated the timing precision in the definitions from datetime to date by adding 'day of', 'date from', and/or function 'ToDateInterval' to align with the measure intent.
Measure Section: Definitions
Source of Change: Measure Lead
Updated the logic to account for the recommended vaccine formulations based on most recent published Advisory Committee on Immunization Practices (ACIP) guidelines.
Measure Section: Definitions
Source of Change: ONC Project Tracking System (JIRA): CQM-5153
Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v7.0.000.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
Updated the logic to remove adverse reaction criteria related to vaccines to align with the intent of the measure.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Replaced the Global.CalendarAgeInYearsAt function with the native CQL function AgeInYearsAt to take advantage of existing CQL features and increase human readability. As a result of this change, the LOINC code 21112-8 is no longer required and has been removed from the Terminology section of the human readable specification.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Updated the version number of the Hospice Library to v4.0.000.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
Updated the version of the Quality Data Model (QDM) to 5.6 and Clinical Quality Language (CQL) to 1.5.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
Value set
The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.
Added direct reference code LOINC code (45755-6) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Removed direct reference code CPT code (90732) based on change in measure requirements/measure specification.
Measure Section: Terminology
Source of Change: Measure Lead
Removed direct reference code SNOMED CT code (293116002) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Removed direct reference code LOINC code (21112-8) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Removed value set Pneumococcal Polysaccharide 23 Vaccine (2.16.840.1.113883.3.464.1003.110.12.1089) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Replaced value set Discharge Services - Nursing Facility (2.16.840.1.113883.3.464.1003.101.11.1065) with value set Discharge Services Nursing Facility (2.16.840.1.113883.3.464.1003.101.12.1013) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Hospice Encounter (2.16.840.1.113883.3.464.1003.1003) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Adult Pneumococcal Vaccine (2.16.840.1.113883.3.464.1003.1161) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set (2.16.840.1.113883.3.464.1003.101.12.1023): Renamed to Preventive Care Services Initial Office Visit, 18 and Up based on recommended value set naming conventions.
Measure Section: Terminology
Source of Change: Annual Update
Value set (2.16.840.1.113883.3.464.1003.101.12.1025): Renamed to Preventive Care Services Established Office Visit, 18 and Up based on recommended value set naming conventions.
Measure Section: Terminology
Source of Change: Annual Update
Value set (2.16.840.1.113883.3.464.1003.101.12.1014): Renamed to Care Services in Long Term Residential Facility based on recommended value set naming conventions.
Measure Section: Terminology
Source of Change: Annual Update
Replaced value set Hospice Care Ambulatory (2.16.840.1.113762.1.4.1108.15) with value set Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added direct reference code SNOMED CT code (373066001) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Adult Pneumococcal Vaccine Administered (2.16.840.1.113883.3.464.1003.1162) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead