Attachment_2_-_IDIQ_SOO_-_Appendix_C.xlsx
XLSX spreadsheet 27 KB Posted
- Attached to
- RFP for Indian Health Service HIT Modernization Federal contract opportunity
- Solicitation number
- 140D0421R0050
About this file
This document includes an attachment related to quality measures for federal reporting programs and a federal contract opportunity notice.
The contract opportunity notice seeks proposals for an IDIQ contract to establish a single award for the Indian Health Service's health information technology modernization efforts, including implementation of an electronic health record. Interested offerors must submit Phase I proposals by September 1, 2022. The Department of the Interior will conduct the source selection on behalf of the Department of Health and Human Services and Indian Health Service. The attachment includes a list of quality measures and reporting programs including eCQMs, UDS measures, and Partnership to Advance Tribal Health measures. It provides measure details such as CMS and NQF IDs, eligible provider types, and comment information.
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Appendix C - Metrics
| Program | eCQM | CMS ID | MIPS ID | 2021 Reporting | Eligible Provider Measure Name | Type | ||
| Eligible Provider (EP) or Eligible Hospital (EH) | Comment | |||||||
| Quality | eCQM | CMS002 | 134 | X | Preventive Care and Screening: Screening for Depression and Follow-Up Plan | EP | ||
| Quality | eCQM | CMS050 | 374 | X | Closing the Referral Loop | EP | ||
| Quality | eCQM | CMS069 | 128 | X | Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | EP | ||
| Quality | eCQM | CMS117 | 240 | X | Child Immunization Status | EP | ||
| Quality | eCQM | CMS122 | 1 | X | Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%) | EP | ||
| Quality | eCQM | CMS124 | 309 | X | Cervical Cancer Screening | EP | ||
| Quality | eCQM | CMS125 | 112 | X | Breast Cancer Screening | EP | ||
| Quality | eCQM | CMS127 | 111 | X | Pneumococcal Vaccination Status for Older Adults | EP | ||
| Quality | eCQM | CMS130 | 113 | X | Colorectal Cancer Screening | EP | ||
| Quality | eCQM | CMS131 | 117 | X | Diabetes: Eye Exam | EP | ||
| Quality | eCQM | CMS134 | 119 | X | Diabetes: Medical Attention for Nephropathy | EP | ||
| Quality | eCQM | CMS137 | 305 | X | Initiation and Engagement of Alcohol and Other Drug Dependence Treatment | EP | ||
| Quality | eCQM | CMS138 | 226 | X | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | EP | ||
| Quality | eCQM | CMS139 | 318 | X | Falls: Screening for Future Fall Risk | EP | ||
| Quality | eCQM | CMS144 | 8 | X | Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction | EP | ||
| Quality | eCQM | CMS155 | 239 | X | Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents | EP | ||
| Quality | eCQM | CMS156 | 238 | X | Use of High-Risk Medications in the Elderly | EP | ||
| Quality | eCQM | CMS159 | 370 | X | Depression Remission at Twelve Months | EP | ||
| Quality | eCQM | CMS160 | 371 | X ? | Depression Utilization of the PHQ-9 Tool | EP | Removed for 2020 performance period | |
| Quality | eCQM | CMS161 | 107 | X | Adult Major Depressive Disorder: Suicide Risk Assessment | EP | ||
| Quality | eCQM | CMS165 | 236 | X | Controlling High Blood Pressure | EP | ||
| Quality | eCQM | CMS177 | 382 | X | Child and Adolescent Major Depressive Disorder: Suicide Risk Assessment | EP | ||
| Quality | eCQM | CMS347 | 438 | X | Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | EP | ||
| Quality | eCQM | CMS349 | 475 | X | HIV Screening | EP | ||
| Quality | eCQM | CMS147v10 | x | Preventive Care and Screening: Influenza Immunization | EP | request to develop for 2021 | ||
| Quality | eCQM | CMS22v9 | x | Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | EP | request to develop for 2021 | ||
| Program | Measure Status | CMS ID | Short Name | *ǂ2021 Reporting | Eligible Hospital Measure Name | Type | ||
| Eligible Provider (EP) or Eligible Hospital (EH) | Comment | |||||||
| Quality | eCQM | CMS009 | PC-05 | X | Exclusive Breast Milk Feeding | EH | ||
| Quality | eCQM | CMS071 | STK-03 | X | Anticoagulation Therapy for Atrial Fibrillation/Flutter | EH | ||
| Quality | eCQM | CMS072 | STK-05 | X | Antithrombotic Therapy By End of Hospital Day 2 | EH | ||
| Quality | eCQM | CMS104 | STK-02 | X | Discharged on Antithrombotic Therapy | EH | ||
| Quality | eCQM | CMS105 | STK-06 | X | Discharged on Statin Medication | EH | ||
| Quality | eCQM | CMS108 | VTE-1 | X | Venous Thromboembolism Prophylaxis | EH | ||
| Quality | eCQM | CMS111 | ED-2 | X | Median Admit Decision Time to ED Departure Time for Admitted Patients | EH | ||
| Quality | eCQM | CMS190 | VTE-2 | X | Intensive Care Unit Venous Thromboembolism Prophylaxis | EH | ||
| Quality | eCQM | CMS506v3 | x | Safe Use of Opioids – Concurrent Prescribing | EH | request to develop for 2021 | ||
| *Must submit a minimum of 4 eCQMs if submitting electronically versus attesting. | ||||||||
| Removed for 2020 performance period | ||||||||
| Program | Measure Status | CMS ID | Short Name | Eligible Hospital Measure Name | Type | |||
| Eligible Provider (EP) or Eligible Hospital (EH) | Comment | |||||||
| Quality | eCQM | CMS026 | CAC-3 | Home Management Plan of Care (HMPC) Document Given to Pt/Caregiver | EH | Removed for 2020 performance period | ||
| Quality | eCQM | CMS031 | EHDI-1a | Hearing Screening Prior To Hospital Discharge | EH | Removed for 2020 performance period | ||
| Quality | eCQM | CMS032 | ED-3 | Median Time from ED Arrival to ED Departure for Discharged ED Patients | EH | Removed for 2020 performance period | ||
| Quality | eCQM | CMS053 | AMI-8a | Primary PCI Received Within 90 Minutes of Hospital Arrival | EH | Removed for 2020 performance period | ||
| Quality | eCQM | CMS055 | ED-1 | Median Time from ED Arrival to ED Departure for Admitted ED Patients | EH | Removed for 2020 performance period | ||
| Quality | eCQM | CMS102 | STK-10 | Assessed for Rehabilitation | EH | Removed for 2020 performance period | ||
| Quality | eCQM | CMS107 | STK-08 | Stroke education | EH | Removed for 2020 performance period | ||
| Quality | eCQM | CMS113 | PC-01 | Elective Delivery | EH | Removed for 2020 performance period | ||
| Eligible Hospital eCQMs- 8/12/19 Outreach done and it was identified to keep all (including the 8 EH eCQM no longer supported by CMS) for IHS for 2020 reportling | ||||||||
| Program | Measure status | CMS ID | NQF | CMIT ref No | 2021 UDS MEASURE | |||
| UDS = Uniform Data Set - HRSA/BPHC reporting for FQHCs | ||||||||
| UDS | eCQM | CMS117v9 | Was 38 | |||||
| Not Endorsed | 5775 | Childhood Immunization Status | ||||||
| UDS | eCQM | CMS124v9 | was 32 | |||||
| Not Endorsed | 5778 | Cervical Cancer Screening | ||||||
| UDS | eCQM | CMS125v9 | Was 2372 | |||||
| Not endorsed | 5778 | Breast Cancer Screening | ||||||
| UDS | eCQM | CMS155v9 | 24 | 5806 | Weight Assessment and Counseling for Nutrition and Physical Activity of Children and Adolescents | |||
| UDS | eCQM | CMS69v9 | 421e | 5835 | Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow-up | |||
| UDS | eCQM | CMS138v9 | 28 | 5792 | Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention | |||
| UDS | eCQM | CMS347v4 | Not endorsed | 2572 | Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | |||
| UDS | eCQM | CMS164v7 | 68 | 692 | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet | |||
| UDS | eCQM | CMS130v9 | Not endorsed | 5784 | Colorectal Cancer Screening | |||
| UDS | eCQM | CMS349v3 | Not endorsed | 5730 | HIV Screening | |||
| UDS | eCQM | CMS002v10 | 0418E | 515 | Depression Measures: Preventative Care and Screening: Screening for Depression and Follow-Up Plan | USHIK LINK | ||
| UDS | eCQM | CMS159v9 | 710e | 5811 | Depression Remission at 12 Months | |||
| UDS | eCQM | CMS227v0 | 2508 CBM | 2892 | Dental Sealants for Children Between 6-9 Years | |||
| UDS | eCQM | CMS165v9 | 0018 | 5816 | Controlling High Blood Pressure | |||
| UDS | eCQM | CMS122v9 | Was 59 | |||||
| Not endorsed | 5776 | Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) | ||||||
| CBM = claims based measure | ||||||||
| Program | Measure status | CMS ID | NQF | CMIT Ref No | Domains Measure Title | |||
| IPC = Improving Patient Care - IHS Patient-Centered Medical Home | ||||||||
| Immunizations | ||||||||
| IPC | CMS117 | NQF 0038 | 5775 | 1) Childhood Immunization Status | ||||
| IPC | NQF 1407 | 2) Adolescents Immunization Status | ||||||
| IPC | 3) Adult Composite Immunization Measure (ACIM). See notes below.* | |||||||
| IPC | CMS147 | NQF 0041 | 4) Influenza Immunization – 6 month and older | |||||
| Chronic Care and Clinical Outcomes | ||||||||
| IPC | 5) Diabetes Comprehensive Care (Bundle) – GPRA Measure | |||||||
| IPC | CMS122 | NQF 0059 | 6) AIC Control > 9 | |||||
| IPC | CMS165 | NQF 0018 | 7) BP Control | |||||
| IPC | NQF 0047 | 8) Asthma Control - Asthma: Pharmacologic Therapy for Persistent Asthma | ||||||
| IPC | CMS69 | NQF 0421 | 9) Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up | |||||
| IPC | CMS155 | NQF 0024 | 10) Weight Assessment/Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) | |||||
| Other Preventive Services | ||||||||
| IPC | CMS130 | NQF 0034 | 11) Colorectal Colon Rectal Screening | |||||
| IPC | CMS125 | NQF 2372 | 12) Breast Cancer Screening (Cross Cutting Measure) Screening and Prevention) | |||||
| IPC | CMS124 | NQF 0032 | 13) Cervical Cancer Screening –with HPV co-testing option Screening | |||||
| Patient Experience | ||||||||
| IPC | 14) Median Waiting Room Time: "Check in" to 1st Vital Signs (as recorded automatically by time stamps). (CRS does not calculate) | |||||||
| Behavioral Health | ||||||||
| IPC | 15) Depression Screening (GPRA) | |||||||
| IPC | NQF 3148 | 16) Follow-Up Plan for Clinical Depression | ||||||
| IPC | CMS159 | NQF 0710 | 17) Depression Remission Rate at 12 Months | |||||
| Population Health System | ||||||||
| IPC | 18) Percentage of patients Empaneled to a Designated Primary Care Provider (DPCP) (CRS does not calculate) | |||||||
| IPC | 19) Continuity of care to a Designated Primary Care Provider (DPCP) (CRS does not calculate) | |||||||
| IPC | 20) Continuity of care to a Designated Care team * Care team= two or more providers (MD, DO (CRS does not calculate) | |||||||
| IPC | 21) Proportion of patients completing planned dental treatment (NEW) | |||||||
| CRS = RPMS Clinical Reporting System | ||||||||
| Program | Global ID | CMS ID | NQF | Patient Safety # | Domains Measure Title | |||
| PATH = Partnership to Advance Tribal Health | ||||||||
| PATH | 1 | PSI 2 | DEATH RATE IN LOW-MORTALITY DIAGNOSIS RELATED GROUPS | |||||
| PATH | 13 | PSI 9 | PERIOPERATIVE HEMORRHAGE OR POSTOPERATIVE HEMATOMA | |||||
| PATH | 13 | PSI 10 | POSTOPERATIVE PHYSIOLOGIC AND METABOLIC DERANGEMENT RATE | |||||
| PATH | 13 | PSI 11 | POSTOPERATIVE RESPIRATORY FAILURE RATE | |||||
| PATH | 13 | PSI 12 | PERIOPERATIVE PULMONARY EMBOLISM OR DEEP VEIN THROMBOSIS | |||||
| PATH | 13 | PSI 14 | POSTOPERATIVE WOUND DEHISCENCE RATE | |||||
| PATH | 15A | ADVERSE DRUG EVENTS (ADE) DUE TO OPIOIDS | ||||||
| PATH | 15B | EXCESSIVE ANTICOAGULATION with WARFARIN - INPATIENT | ||||||
| PATH | 15C | HYPOGLYCEMIA in INPATIENTS RECEIVING INSULIN | ||||||
| PATH | 6 | 0418 PI | SCREENING FOR DEPRESSION AND FOLLOW-UP PLAN | |||||
| PATH | 7a | 0041 | INFUENZA IMMUNIZATIONS -6 MONTHS AND OLDER | |||||
| PATH | 7b | 0043 | INFUENZA IMMUNIZATIONS -6 MONTHS AND OLDER | |||||
| PATH | 8 | 0202 | FALLS WITH INJURY |
https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=5784https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=5730https://ushik.ahrq.gov/ViewItemDetails?&system=mu&itemKey=226822000https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=515https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=5811https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=2892https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=5816https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=5776https://cmit.cms.gov/CMIT_public/ListMeasures?struts.token.name=token&token=1W7R5UN4DEELCE8APRGTTZ8GRKSLPGQG&filters=Status_untok%7Cd%7CActive&view=&makeStick=&wasSearchSubmitted=true&q=cms117v9https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=5778https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=5779https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=5806https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=5835https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=5792https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=2572https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=692
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