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
Issued by
Department of the Interior Departmental Offices Interior Business Center

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

ProgrameCQMCMS IDMIPS ID2021 ReportingEligible Provider Measure NameType
Eligible Provider (EP) or Eligible Hospital (EH)Comment
QualityeCQMCMS002134XPreventive Care and Screening: Screening for Depression and Follow-Up PlanEP
QualityeCQMCMS050374XClosing the Referral LoopEP
QualityeCQMCMS069128XPreventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up PlanEP
QualityeCQMCMS117240XChild Immunization StatusEP
QualityeCQMCMS1221XDiabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)EP
QualityeCQMCMS124309XCervical Cancer ScreeningEP
QualityeCQMCMS125112XBreast Cancer ScreeningEP
QualityeCQMCMS127111XPneumococcal Vaccination Status for Older AdultsEP
QualityeCQMCMS130113XColorectal Cancer ScreeningEP
QualityeCQMCMS131117XDiabetes: Eye ExamEP
QualityeCQMCMS134119XDiabetes: Medical Attention for NephropathyEP
QualityeCQMCMS137305XInitiation and Engagement of Alcohol and Other Drug Dependence TreatmentEP
QualityeCQMCMS138226XPreventive Care and Screening: Tobacco Use: Screening and Cessation InterventionEP
QualityeCQMCMS139318XFalls: Screening for Future Fall RiskEP
QualityeCQMCMS1448XHeart Failure: Beta-Blocker Therapy for Left Ventricular Systolic DysfunctionEP
QualityeCQMCMS155239XWeight Assessment and Counseling for Nutrition and Physical Activity for Children and AdolescentsEP
QualityeCQMCMS156238XUse of High-Risk Medications in the ElderlyEP
QualityeCQMCMS159370XDepression Remission at Twelve MonthsEP
QualityeCQMCMS160371X ?Depression Utilization of the PHQ-9 ToolEPRemoved for 2020 performance period
QualityeCQMCMS161107XAdult Major Depressive Disorder: Suicide Risk AssessmentEP
QualityeCQMCMS165236XControlling High Blood PressureEP
QualityeCQMCMS177382XChild and Adolescent Major Depressive Disorder: Suicide Risk AssessmentEP
QualityeCQMCMS347438XStatin Therapy for the Prevention and Treatment of Cardiovascular DiseaseEP
QualityeCQMCMS349475XHIV ScreeningEP
QualityeCQMCMS147v10xPreventive Care and Screening: Influenza ImmunizationEPrequest to develop for 2021
QualityeCQMCMS22v9xPreventive Care and Screening: Screening for High Blood Pressure and Follow-Up DocumentedEPrequest to develop for 2021
ProgramMeasure StatusCMS IDShort Name*ǂ2021 ReportingEligible Hospital Measure NameType
Eligible Provider (EP) or Eligible Hospital (EH)Comment
QualityeCQMCMS009PC-05XExclusive Breast Milk FeedingEH
QualityeCQMCMS071STK-03XAnticoagulation Therapy for Atrial Fibrillation/FlutterEH
QualityeCQMCMS072STK-05XAntithrombotic Therapy By End of Hospital Day 2EH
QualityeCQMCMS104STK-02XDischarged on Antithrombotic TherapyEH
QualityeCQMCMS105STK-06XDischarged on Statin MedicationEH
QualityeCQMCMS108VTE-1XVenous Thromboembolism ProphylaxisEH
QualityeCQMCMS111ED-2XMedian Admit Decision Time to ED Departure Time for Admitted PatientsEH
QualityeCQMCMS190VTE-2XIntensive Care Unit Venous Thromboembolism ProphylaxisEH
QualityeCQMCMS506v3xSafe Use of Opioids – Concurrent PrescribingEHrequest to develop for 2021
*Must submit a minimum of 4 eCQMs if submitting electronically versus attesting.
Removed for 2020 performance period
ProgramMeasure StatusCMS IDShort NameEligible Hospital Measure NameType
Eligible Provider (EP) or Eligible Hospital (EH)Comment
QualityeCQMCMS026CAC-3Home Management Plan of Care (HMPC) Document Given to Pt/CaregiverEHRemoved for 2020 performance period
QualityeCQMCMS031EHDI-1aHearing Screening Prior To Hospital DischargeEHRemoved for 2020 performance period
QualityeCQMCMS032ED-3Median Time from ED Arrival to ED Departure for Discharged ED PatientsEHRemoved for 2020 performance period
QualityeCQMCMS053AMI-8aPrimary PCI Received Within 90 Minutes of Hospital ArrivalEHRemoved for 2020 performance period
QualityeCQMCMS055ED-1Median Time from ED Arrival to ED Departure for Admitted ED PatientsEHRemoved for 2020 performance period
QualityeCQMCMS102STK-10Assessed for RehabilitationEHRemoved for 2020 performance period
QualityeCQMCMS107STK-08Stroke educationEHRemoved for 2020 performance period
QualityeCQMCMS113PC-01Elective DeliveryEHRemoved 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
ProgramMeasure statusCMS IDNQFCMIT ref No2021 UDS MEASURE
UDS = Uniform Data Set - HRSA/BPHC reporting for FQHCs
UDSeCQMCMS117v9Was 38
Not Endorsed5775Childhood Immunization Status
UDSeCQMCMS124v9was 32
Not Endorsed5778Cervical Cancer Screening
UDSeCQMCMS125v9Was 2372
Not endorsed5778Breast Cancer Screening
UDSeCQMCMS155v9245806Weight Assessment and Counseling for Nutrition and Physical Activity of Children and Adolescents
UDSeCQMCMS69v9421e5835Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow-up
UDSeCQMCMS138v9285792Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention
UDSeCQMCMS347v4Not endorsed2572Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
UDSeCQMCMS164v768692Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet
UDSeCQMCMS130v9Not endorsed5784Colorectal Cancer Screening
UDSeCQMCMS349v3Not endorsed5730HIV Screening
UDSeCQMCMS002v100418E515Depression Measures: Preventative Care and Screening: Screening for Depression and Follow-Up PlanUSHIK LINK
UDSeCQMCMS159v9710e5811Depression Remission at 12 Months
UDSeCQMCMS227v02508 CBM2892Dental Sealants for Children Between 6-9 Years
UDSeCQMCMS165v900185816Controlling High Blood Pressure
UDSeCQMCMS122v9Was 59
Not endorsed5776Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
CBM = claims based measure
ProgramMeasure statusCMS IDNQFCMIT Ref NoDomains Measure Title
IPC = Improving Patient Care - IHS Patient-Centered Medical Home
Immunizations
IPCCMS117NQF 003857751) Childhood Immunization Status
IPCNQF 14072) Adolescents Immunization Status
IPC3) Adult Composite Immunization Measure (ACIM). See notes below.*
IPCCMS147NQF 00414) Influenza Immunization – 6 month and older
Chronic Care and Clinical Outcomes
IPC5) Diabetes Comprehensive Care (Bundle) – GPRA Measure
IPCCMS122NQF 00596) AIC Control > 9
IPCCMS165NQF 00187) BP Control
IPCNQF 00478) Asthma Control - Asthma: Pharmacologic Therapy for Persistent Asthma
IPCCMS69NQF 04219) Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
IPCCMS155NQF 002410) Weight Assessment/Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)
Other Preventive Services
IPCCMS130NQF 003411) Colorectal Colon Rectal Screening
IPCCMS125NQF 237212) Breast Cancer Screening (Cross Cutting Measure) Screening and Prevention)
IPCCMS124NQF 003213) Cervical Cancer Screening –with HPV co-testing option Screening
Patient Experience
IPC14) Median Waiting Room Time: "Check in" to 1st Vital Signs (as recorded automatically by time stamps). (CRS does not calculate)
Behavioral Health
IPC15) Depression Screening (GPRA)
IPCNQF 314816) Follow-Up Plan for Clinical Depression
IPCCMS159NQF 071017) Depression Remission Rate at 12 Months
Population Health System
IPC18) Percentage of patients Empaneled to a Designated Primary Care Provider (DPCP) (CRS does not calculate)
IPC19) Continuity of care to a Designated Primary Care Provider (DPCP) (CRS does not calculate)
IPC20) Continuity of care to a Designated Care team * Care team= two or more providers (MD, DO (CRS does not calculate)
IPC21) Proportion of patients completing planned dental treatment (NEW)
CRS = RPMS Clinical Reporting System
ProgramGlobal IDCMS IDNQFPatient Safety #Domains Measure Title
PATH = Partnership to Advance Tribal Health
PATH1PSI 2DEATH RATE IN LOW-MORTALITY DIAGNOSIS RELATED GROUPS
PATH13PSI 9PERIOPERATIVE HEMORRHAGE OR POSTOPERATIVE HEMATOMA
PATH13PSI 10POSTOPERATIVE PHYSIOLOGIC AND METABOLIC DERANGEMENT RATE
PATH13PSI 11POSTOPERATIVE RESPIRATORY FAILURE RATE
PATH13PSI 12PERIOPERATIVE PULMONARY EMBOLISM OR DEEP VEIN THROMBOSIS
PATH13PSI 14POSTOPERATIVE WOUND DEHISCENCE RATE
PATH15AADVERSE DRUG EVENTS (ADE) DUE TO OPIOIDS
PATH15BEXCESSIVE ANTICOAGULATION with WARFARIN - INPATIENT
PATH15CHYPOGLYCEMIA in INPATIENTS RECEIVING INSULIN
PATH60418 PISCREENING FOR DEPRESSION AND FOLLOW-UP PLAN
PATH7a0041INFUENZA IMMUNIZATIONS -6 MONTHS AND OLDER
PATH7b0043INFUENZA IMMUNIZATIONS -6 MONTHS AND OLDER
PATH80202FALLS 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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