CMS125v3 Breast Cancer Screening

Header:
Numerator: Women with one or more mammograms during the measurement period or the year prior to the measurement period.
(meaning this screening should happen every 2 years.)

Population Criteria:
Numerator =
• AND: "Diagnostic Study, Result: Mammogram (result)" <= 12 month(s) ends before or during "Measurement Period"
At the first glance, the numerator criterion seems right but it is actually not correct. If the measurement period is 1/1/2015 to 12/31/2015, it will look at mammogram with an end timestamp during the range of 12/1/2014 to 12/31/2015 (measure intent: 1/1/2014 to 12/31/2015). We tested using Bonnie tool and had some discussion with Balu at QDM Jira(QDM-117).

The questions include how one applies <= 12 months temporal criteria. According to the HQMF and QDM, “<=12 months” of this measure should compare to the end of the measurement period. Also, any time interval should be rounded down to the unit ‘month’. For example, 12 months 29 days (in most cases) will be considered as 12 months and so be considered as “<= 12 months”. So, “<= 12 months” is close to “< 13 months”. Using the same way of interpretation, we can calculate CMS124v3, CMS130v3 (both have the similar phrase "ends before or during Measurement Period") with results consistent with measure intents. The incorrect measure is only CMS125v3 and versions before. CMS125v4 has corrected the mistake by changing the time criteria to “<24 months”

The issue we are facing is:

For the year 2015, we need to use CMS125v3 (July2014), in which measure logic (population criteria) is inconsistent with measure intent.
• If we follow the logic, the result will not match the measure intent. “Mammogram every 2 years” is well perceived clinically. The calculation generates a result different from this perception.
• If we follow the measure intent, we deviate from the eCQM spec, which may also imply we deviate from the module we certified. However, it would make more sense to clinicians.

We will appreciate guidance for measure calcuation. An answer in FAQ or Jira will be very helpful.