Electronic Health Records

This quarterly measure identifies the average percentage of healthcare personnel (HCP) who are considered up to date with recommended COVID-19 vaccines among the total number of HCP who regularly work in the facility.  

The measure is reported for a quarter (3-month period). The quarterly COVID-19 vaccination coverage is determined by selecting one week per month and calculating the percentage of HCP who are considered up to date with recommended COVID-19 vaccines, then averaging 3 weekly percentages (one week from each of the 3 months in the quarter).

This electronic Clinical Quality Measure (eCQM) reports the percentage of female patients aged 40 to 75 years with at least one abnormal screening (BI-RADS 0) or screening-to-diagnostic (BI-RADS 4, 5) mammogram during the measurement period (i.e., calendar year) who received timely diagnostic resolution defined as either follow-up imaging with negative/benign/probably benign results or a breast biopsy within 60 days after their index (i.e., first) abnormal screening mammogram.

This electronic Clinical Quality Measure (eCQM) reports the percentage of patients aged 45 to 75 years with at least one positive stool-based colorectal cancer screening test (i.e., high-sensitivity guaiac fecal occult blood test, fecal immunochemical test, or Cologuard) during the measurement period (i.e., calendar year) who completed a colonoscopy within 180 days after their index (i.e., first) positive stool-based test result date.

Proportion of inpatient hospitalizations for patients 18 years of age and older prescribed, or continued on, two or more opioids or an opioid and benzodiazepine concurrently at discharge.

Percentage of women who 1) received or had documented use of most or moderately effective contraception and 2) received a long-acting reversible contraceptive method during the calendar year. 

To focus the measure  on the population of women interested in contraceptive services, the denominator excludes those individuals who did not receive or have documented use of a method if they indicated during the year that they did not want these services, as well as those who are eligible for postpartum contraceptive services during the measurement period.

Percentage of women 1) who received or had documented use of most or moderately effective contraception during the postpartum period (primary measure) and 2) received a long-acting reversible contraceptive method during the postpartum period (sub-measure). To focus the measure on the population of women interested in contraceptive services, the denominator excludes those individuals who did not receive or have documented use of a method if they indicated they did not want these services. 

Percentage of patients 13 years of age and older with a diagnosis of HIV who had tests for syphilis, gonorrhea, and chlamydia performed within the measurement period.

Percentage of patients assigned female at birth and ages 15-44 who were asked if they wanted to talk about contraception or pregnancy prevention and had their response recorded during the measurement period (which is a calendar year), among patients with a qualifying encounter; to focus on the population of non-postpartum women, the measure excludes those individuals who had a live birth making them eligible for postpartum contraceptive services, and also excludes those who are anatomically infecund or  have had female sterilization from the denominator.

This metric is designed to measure the critical care transport team's utilization of waveform capnography during critical care medical transport.  Waveform capnography has evolved as the standard for the safe placement and maintenance of advanced airways (e.g., endotracheal tubes) in adult and pediatric patients.  The metric specifically focuses on transported patients with advanced airways in whom continuous waveform capnography is appropriately used.  This metric is stratified by age into the following three categories: neonatal (defined as infants <29 days), pediatric (