eCQM Title | Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented |
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eCQM Identifier (Measure Authoring Tool) | 22 | eCQM Version number | 7.1.000 |
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 | Quality Insights | ||
Endorsed By | None | ||
Description | |||
Copyright | |||
Disclaimer | |||
Measure Scoring | Proportion | ||
Measure Type | Process | ||
Stratification | |||
Risk Adjustment | |||
Rate Aggregation | |||
Rationale | |||
Clinical Recommendation Statement | |||
Improvement Notation | |||
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Definition | |||
Guidance | |||
Transmission Format | |||
Initial Population | |||
Denominator | |||
Denominator Exclusions | |||
Numerator | |||
Numerator Exclusions | |||
Denominator Exceptions | |||
Supplemental Data Elements |
"Patients Age 18 Years and Older at Start of Measurement Period" and exists ( "Qualifying Encounters During Measurement Period" )
"Initial Population"
exists ( ["Diagnosis": "Diagnosis of hypertension"] Hypertension with "Qualifying Encounters During Measurement Period" QualifyingEncounter such that Hypertension.prevalencePeriod starts before start of QualifyingEncounter.relevantPeriod )
( "Blood Pressure Normal at Most Recent Screening Encounter" is not null ) or ( "Has Prehypertensive Reading With Interventions" ) or ( "Has First Hypertensive Reading With Interventions" ) or ( "Has Second Hypertensive Reading With Interventions" )
exists ( "No Blood Pressure Screen Due to Medical Reason or Patient Refusal" ) or exists ( "Hypertensive Followup Interventions Not Ordered Due to Patient Refusal" ) or exists ( "Antihypertensive Medication Not Ordered Due to Patient Refusal" ) or exists ( "Lab Test for Hypertension Not Ordered Due to Patient Refusal" ) or exists ( "Diagnostic Study Not Ordered Due to Patient Refusal" )
( ["Medication, Not Ordered": "Anti-Hypertensive Pharmacologic Therapy"] NoAntihypertensives with "Qualifying Encounters During Measurement Period" QualifyingEncounter such that NoAntihypertensives.negationRationale in "Patient Reason refused" and NoAntihypertensives.authorDatetime same day as start of QualifyingEncounter.relevantPeriod )
["Medication, Order": "Anti-Hypertensive Pharmacologic Therapy"] AntihypertensiveMeds with "Most Recent Blood Pressure Screening Encounter" LastBPEncounter such that AntihypertensiveMeds.authorDatetime same day as start of LastBPEncounter.relevantPeriod
from "Most Recent Systolic Reading During Most Recent Blood Pressure Screening Encounter" LastSystolicBP, "Most Recent Diastolic Reading During Most Recent Blood Pressure Screening Encounter" LastDiastolicBP where ( LastSystolicBP.result < 120 'mm[Hg]' and LastDiastolicBP.result < 80 'mm[Hg]' )
"Initial Population"
exists ( "No Blood Pressure Screen Due to Medical Reason or Patient Refusal" ) or exists ( "Hypertensive Followup Interventions Not Ordered Due to Patient Refusal" ) or exists ( "Antihypertensive Medication Not Ordered Due to Patient Refusal" ) or exists ( "Lab Test for Hypertension Not Ordered Due to Patient Refusal" ) or exists ( "Diagnostic Study Not Ordered Due to Patient Refusal" )
exists ( ["Diagnosis": "Diagnosis of hypertension"] Hypertension with "Qualifying Encounters During Measurement Period" QualifyingEncounter such that Hypertension.prevalencePeriod starts before start of QualifyingEncounter.relevantPeriod )
( ["Diagnostic Study, Not Ordered": "ECG 12 lead or study order"] NoDiagnosticStudy with "Qualifying Encounters During Measurement Period" QualifyingEncounter such that NoDiagnosticStudy.negationRationale in "Patient Reason refused" and NoDiagnosticStudy.authorDatetime same day as start of QualifyingEncounter.relevantPeriod )
["Diagnostic Study, Order": "ECG 12 lead or study order"] ECG with "Most Recent Blood Pressure Screening Encounter" LastBPEncounter such that ECG.authorDatetime same day as start of LastBPEncounter.relevantPeriod
["Intervention, Order": "Followup within one year"] FollowupOneYear with "Most Recent Blood Pressure Screening Encounter" LastBPEncounter such that FollowupOneYear.authorDatetime same day as start of LastBPEncounter.relevantPeriod
["Intervention, Order": "Followup within 4 weeks"] Followup4Weeks with "Most Recent Blood Pressure Screening Encounter" LastBPEncounter such that Followup4Weeks.authorDatetime same day as start of LastBPEncounter.relevantPeriod
"High Blood Pressure at Most Recent Screening Encounter" is not null and not "Last Blood Pressure Within One Year High" and ( exists ( "Hypertensive Interventions at Most Recent Blood Pressure Encounter" ) and exists ( "Follow Up Within 4 Weeks" ) ) or exists ( "Referral to Alternate Provider" )
"Prehypertensive Blood Pressure at Most Recent Screening Encounter" is not null and ( exists ( "Hypertensive Interventions at Most Recent Blood Pressure Encounter" ) and "Follow Up One Year" is not null ) or exists ( "Referral to Alternate Provider" )
"Last Blood Pressure Within One Year High" and "High Blood Pressure at Most Recent Screening Encounter" is not null
"Has Second Hypertensive Reading" and ( "Hypertensive Interventions at Most Recent Blood Pressure Encounter" is not null and "Interventions for Second Hypertensive Reading" ) or exists ( "Referral to Alternate Provider" )
from "Most Recent Systolic Reading During Most Recent Blood Pressure Screening Encounter" LastSystolicBP, "Most Recent Diastolic Reading During Most Recent Blood Pressure Screening Encounter" LastDiastolicBP where ( LastSystolicBP.result >= 140 'mm[Hg]' or LastDiastolicBP.result >= 90 'mm[Hg]' )
["Intervention, Not Ordered": "Referral to Alternative Provider / Primary Care Provider"] union ["Intervention, Not Ordered": "Lifestyle Recommendation"] union ["Intervention, Not Ordered": "Weight Reduction Recommended"] union ["Intervention, Not Ordered": "Dietary Recommendations"] union ["Intervention, Not Ordered": "Physical Activity Recommendation"] union ["Intervention, Not Ordered": "Moderation of ETOH Consumption Recommendation"]
"Hypertensive Followup Interventions Not Ordered" NoInterventions with "Qualifying Encounters During Measurement Period" QualifyingEncounter such that NoInterventions.negationRationale in "Patient Reason refused" and NoInterventions.authorDatetime same day as start of QualifyingEncounter.relevantPeriod
["Intervention, Order": "Lifestyle Recommendation"] union ["Intervention, Order": "Weight Reduction Recommended"] union ["Intervention, Order": "Dietary Recommendations"] union ["Intervention, Order": "Physical Activity Recommendation"] union ["Intervention, Order": "Moderation of ETOH Consumption Recommendation"]
"Hypertensive Interventions" HighBloodPressureInterventions with "Most Recent Blood Pressure Screening Encounter" MostRecentBloodPressureEncounter such that HighBloodPressureInterventions.authorDatetime same day as start of MostRecentBloodPressureEncounter.relevantPeriod
"Patients Age 18 Years and Older at Start of Measurement Period" and exists ( "Qualifying Encounters During Measurement Period" )
exists ( "Antihypertensive Medications Ordered" ) or exists ( "Labs Ordered for Hypertension" ) or exists ( "Electrocardiogram Ordered for Hypertension" )
( ["Laboratory Test, Not Ordered": "Laboratory Tests for Hypertension"] NoLabsOrdered with "Qualifying Encounters During Measurement Period" QualifyingEncounter such that NoLabsOrdered.negationRationale in "Patient Reason refused" and NoLabsOrdered.authorDatetime same day as start of QualifyingEncounter.relevantPeriod )
["Laboratory Test, Order": "Laboratory Tests for Hypertension"] HypertensionLabs with "Most Recent Blood Pressure Screening Encounter" LastBPEncounter such that HypertensionLabs.authorDatetime same day as start of LastBPEncounter.relevantPeriod
"Last Diastolic One Year Prior to Encounter High" is not null or "Last Systolic One Year Prior to Encounter High" is not null
Last(["Physical Exam, Performed": "Diastolic blood pressure"] DiastolicBP with "Most Recent Blood Pressure Screening Encounter" LastBPEncounter such that DiastolicBP.relevantPeriod starts 1 year or less before start LastBPEncounter.relevantPeriod sort by start of relevantPeriod )
"Last Diastolic One Year Prior to Encounter" LastDiastolic where LastDiastolic.result >= 90 'mm[Hg]'
Last(["Physical Exam, Performed": "Systolic blood pressure"] SystolicBP with "Most Recent Blood Pressure Screening Encounter" LastBPEncounter such that SystolicBP.relevantPeriod starts 1 year or less before start LastBPEncounter.relevantPeriod sort by start of relevantPeriod )
"Last Systolic One Year Prior to Encounter" LastSystolic where LastSystolic.result >= 140 'mm[Hg]'
Last("Qualifying Encounters with Blood Pressure Screening Results")
Last(["Physical Exam, Performed": "Diastolic blood pressure"] DiastolicBP with "Most Recent Blood Pressure Screening Encounter" LastBPEncounter such that DiastolicBP.relevantPeriod during LastBPEncounter.relevantPeriod and DiastolicBP.result is not null sort by start of relevantPeriod )
Last(["Physical Exam, Performed": "Systolic blood pressure"] SystolicBP with "Most Recent Blood Pressure Screening Encounter" LastBPEncounter such that SystolicBP.relevantPeriod during LastBPEncounter.relevantPeriod and SystolicBP.result is not null sort by start of relevantPeriod )
["Physical Exam, Not Performed": "Systolic blood pressure"] union ["Physical Exam, Not Performed": "Diastolic blood pressure"]
"No Blood Pressure Screen" NoBPScreen with "Qualifying Encounters During Measurement Period" QualifyingEncounter such that ( NoBPScreen.negationRationale in "Medical or Other reason not done" or NoBPScreen.negationRationale in "Patient Reason refused" ) and NoBPScreen.authorDatetime same day as start of QualifyingEncounter.relevantPeriod
( "Blood Pressure Normal at Most Recent Screening Encounter" is not null ) or ( "Has Prehypertensive Reading With Interventions" ) or ( "Has First Hypertensive Reading With Interventions" ) or ( "Has Second Hypertensive Reading With Interventions" )
exists ["Patient Characteristic Birthdate"] BirthDate where Global."CalendarAgeInYearsAt"(BirthDate.birthDatetime, start of "Measurement Period")>= 18
from "Most Recent Systolic Reading During Most Recent Blood Pressure Screening Encounter" LastSystolicBP, "Most Recent Diastolic Reading During Most Recent Blood Pressure Screening Encounter" LastDiastolicBP where ( LastSystolicBP.result >= 120 'mm[Hg]' or LastDiastolicBP.result >= 80 'mm[Hg]' ) and LastSystolicBP.result < 140 'mm[Hg]' and LastDiastolicBP.result < 90 'mm[Hg]'
["Encounter, Performed": "BP Screening Encounter Codes"] QualifyingEncounter where QualifyingEncounter.relevantPeriod during "Measurement Period"
"Qualifying Encounters During Measurement Period" QualifyingEncounter with ["Physical Exam, Performed": "Diastolic blood pressure"] DiastolicBP such that DiastolicBP.relevantPeriod starts during QualifyingEncounter.relevantPeriod and DiastolicBP.result is not null with ["Physical Exam, Performed": "Systolic blood pressure"] SystolicBP such that SystolicBP.relevantPeriod starts during QualifyingEncounter.relevantPeriod and SystolicBP.result is not null sort by start of relevantPeriod
( ["Intervention, Order": "Referral to Alternative Provider / Primary Care Provider"] Referral with "Most Recent Blood Pressure Screening Encounter" LastBPEncounter such that Referral.authorDatetime same day as start of LastBPEncounter.relevantPeriod )
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
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 |