Brief Description of Measure:
​CMS122 Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)

Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period

CMS125: Breast Cancer Screening

Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the Measurement Period

CMS130: Colorectal Cancer Screening

Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer

CMS131: Diabetes: Eye Exam

Percentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or diabetics with no diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or in the 12 months prior to the measurement period

CMS134: Diabetes: Medical Attention for Nephropathy

The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period

CMS165: Controlling High Blood Pressure

Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period

Description of Issue:
The indicated measures contain an exclusion for long-term care, with the intention of excluding patients living long-term in a facility due to certain care needs that impact health status. This exclusion is a derivative of the HEDIS health plan specification, where Medicare members 66 years of age and older as of December 31 of the measurement year who live long-term in an institution any time during the measurement year as identified by the LTI flag in the Monthly Membership Detail Data File are excluded.

During the last annual update cycle, technical review teams suggested that most primary care providers who see patients at an extended care facility will document in that facility's EHR which would usually be on a different network from their office EHR. Their office EHR might contain a brief note, communication or perhaps a copy of the facility note as unstructured data. As such, "Encounter, Performed'.relevantPeriod could represent the duration of the note entry, instead of the duration of patient stay in long-term care.

The measure developer has considered the feedback that the codes in value sets "Care Services in Long-Term Residential Facility" and "Nursing Facility Visit" found in office EHRs would not represent patient duration of stay in a long term care facility, hence calculating total duration based on "Encounter, Performed".relevantPeriod would not be accurate.

As such, other approaches (e.g., Assessment of housing status indicating result of patient living in nursing home, or Condition/Diagnosis/Problem of patient transitioning into long-term care) have been considered to replace the current specification. The conclusion is that looking for the most recent assessment of housing status completed any time before the end of the measurement period with a result showing that the patient lives in a nursing home would best meet the intent of the exclusion.

Below is the current specification:

//Terminology
valueset "Care Services in Long-Term Residential Facility": 'urn:oid:2.16.840.1.113883.3.464.1003.101.12.1014'
valueset "Nursing Facility Visit": 'urn:oid:2.16.840.1.113883.3.464.1003.101.12.1012'

//Logic
define "Long Term Care Periods in Measurement Period":
collapse(( ["Encounter, Performed": "Care Services in Long-Term Residential Facility"]
union ["Encounter, Performed": "Nursing Facility Visit"] ) LongTermFacilityEncounter
where LongTermFacilityEncounter.relevantPeriod overlaps "Measurement Period"
return LongTermFacilityEncounter.relevantPeriod
intersect "Measurement Period")

define "Long Term Care Overlapping Periods":
collapse("Long Term Care Periods During Measurement Period")

define "Long Term Care Adjacent Periods":
from
"Long Term Care Periods in Measurement Period" LTCPeriod1,
"Long Term Care Periods in Measurement Period" LTCPeriod2
where end of LTCPeriod1 within 1 day of start of LTCPeriod2
return Interval[start of LTCPeriod1, end of LTCPeriod2]

define "Max Long Term Care Period Length":
Max((collapse("Long Term Care Periods in Measurement Period"
union "Long Term Care Adjacent Periods"
))LTCPeriods
return duration in days of LTCPeriods )

define "Has Long Term Care Periods Longer Than 90 Consecutive Days":
"Max Long Term Care Period Length" > 90

Proposed Solution:
Replace the current specification for the exclusion intended to capture patients receiving long-term care with logic and coding that looks for the most recent assessment of housing status completed any time before the end of the measurement period with a result showing that the patient lives in a nursing home.
Proposed specification:

//Terminology
code "Housing status": '71802-3' from "LOINC" display 'Housing status'
code "Lives in a nursing home (finding)": '160734000' from "SNOMEDCT" display 'Lives in a nursing home (finding)'

//Logic
define "Living Long Term in a Nursing Home":
  ( Last(["Assessment, Performed": "Housing status"] HousingStatus
      where Global."NormalizeInterval"(HousingStatus.relevantDatetime, HousingStatus.relevantPeriod)ends on or before
      end of "Measurement Period"
      sort by
      end of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)asc
  )) LastHousingStatus
    where LastHousingStatus.result ~ "Lives in a nursing home (finding)"
Rationale for Change:
The proposed solution will address the data feasibility concerns expressed by eCQM technical/standards reviewers, which we hope allow implementers to more accurately identify patients meeting the intended exclusion criteria using their electronic records.