Brief Description of Measure:

​CMS117: Childhood Immunization Status:
Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three or four H influenza type B (Hib); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday
CMS127: Pneumococcal Vaccination Status for Older Adults:
Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine

Description of Issue:

We received feedback from implementers that our current modeling approach for adverse reaction criteria is infeasible. Currently, we use the Diagnosis datatype in QDM, and we heard this does not reflect how the data are actually captured in an EHR. This change aligns with your HEDIS MY2022 parent measures.

Proposed Solution:

​//CMS127

Before

//Numerator
Patients who received a pneumococcal vaccination on or after their 60th birthday and before the end of the measurement period; or ever had an adverse reaction to the vaccine before the end of the measurement period

//Terminology
code "Adverse reaction to vaccine product containing Streptococcus pneumoniae antigen (disorder)" ("SNOMEDCT Code (293116002)") 

//Logic
define "Numerator":
"Has Pneumococcal Polysaccharide Vaccine 23 Administered"
or "Has Pneumococcal Vaccine Adverse Reaction" 

define "Has Pneumococcal Vaccine Adverse Reaction":
exists ["Diagnosis": "Adverse reaction to vaccine product containing Streptococcus pneumoniae antigen (disorder)"] PneumococcalAdverseRXN
  where PneumococcalAdverseRXN.prevalencePeriod starts on or before 
  end of "Measurement Period" 

After

//Numerator
Patients who received a pneumococcal vaccination on or after their 60th birthday and before the end of the measurement period

//Logic

define "Numerator":
"Has Pneumococcal Polysaccharide Vaccine 23 Administered"

CMS117 Proposed Changes 

//Current DRC:
•code "Adverse reaction to vaccine product containing Hepatitis A virus antigen (disorder)" ("SNOMEDCT Code (293126009)")
•code "Adverse reaction to vaccine product containing Human poliovirus antigen (disorder)" ("SNOMEDCT Code (293117006)")
•code "Adverse reaction to vaccine product containing Influenza virus antigen (disorder)" ("SNOMEDCT Code (420113004)")
•code "Adverse reaction to vaccine product containing Streptococcus pneumoniae antigen (disorder)" ("SNOMEDCT Code (293116002)") 
•code "Neomycin adverse reaction (disorder)" ("SNOMEDCT Code (292927007)") 
•code "Polymyxin B adverse reaction (disorder)" ("SNOMEDCT Code (292992006)") 
•code "Streptomycin adverse reaction (disorder)" ("SNOMEDCT Code (292925004)")

//Proposed DRC:
Remove the DRC listed above

//Current Guidance:
Numerator criteria includes evidence of receipt of the recommended vaccine or the following:
– DTaP:
Adverse reaction to the DTaP or Td vaccine; or encephalopathy due to DTaP or Td vaccination 
– Polio (IPV) vaccine: 
Adverse reaction to the IPV vaccine, streptomycin, polymyxin B, or neomycin
– MMR Vaccination:
Immunodeficiency, HIV, lymphoreticular cancer, multiple myeloma, or leukemia; adverse reaction to neomycin; history of measles, mumps, or rubella; or a seropositive result for the antigens  
– Hib:
Adverse reaction to the Hib vaccine 
– Hepatitis B:
Seropositive result for the antigen, adverse reaction to the hepatitis B vaccine, adverse reaction to common baker’s yeast, or a history of hepatitis B illness
– Chicken pox (varicella zoster): 
Seropositive result for the antigen; immunodeficiency, HIV, lymphoreticular cancer, multiple myeloma, or leukemia; adverse reaction to neomycin; or a history of varicella zoster
– Pneumococcal:
Adverse reaction to the pneumococcal vaccine
– Hepatitis A:
Seropositive result for the antigen, adverse reaction to the hepatitis A vaccine, or a history of hepatitis A illness
– Rotavirus:
Adverse reaction to the rotavirus vaccine, severe combined immunodeficiency, or a history of intussusception 
– Influenza:  
Adverse reaction to the influenza vaccine; immunodeficiency, HIV, lymphoreticular cancer, multiple myeloma, or leukemia; or adverse reaction to neomycin......

//Proposed Guidance: 
The measure allows a grace period by measuring compliance with these recommendations between birth and age two.

This eCQM is a patient-based measure.
 
This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

//Current logic:
Numerator
( exists ( "Four DTaP Vaccinations" )
    or exists ( "DTaP Numerator Inclusion Conditions" )
)
  and ( exists ( "Three Polio Vaccinations" )
      or exists ( "Polio Numerator Inclusion Conditions" )
  )
  and ( exists ( "One MMR Vaccination" )
      or exists ( "MMR Numerator Inclusion Conditions" )
      or ( exists ( "Measles Indicators" )
          and exists ( "Mumps Indicators" )
          and exists ( "Rubella Indicators" )
      )
  )

  and ( "Has Appropriate Number of Hib Immunizations"
      or exists ( "Hib Numerator Inclusion Conditions" )
  )
  and ( exists ( "Three Hepatitis B Vaccinations" )
      or exists ( "Hepatitis B Numerator Inclusion Conditions" )
  )
  and ( exists ( "One Chicken Pox Vaccination" )
      or exists ( "Varicella Zoster Numerator Inclusion Conditions" )
  )
  and ( exists ( "Four Pneumococcal Conjugate Vaccinations" )
      or exists ( "Pneumococcal Conjugate Numerator Inclusion Conditions" )
  )
  and ( exists ( "One Hepatitis A Vaccinations" )
      or exists ( "Hepatitis A Numerator Inclusion Conditions" )
  )
  and ( "Has Appropriate Number of Rotavirus Immunizations"
      or exists ( "Rotavirus Numerator Inclusion Conditions" )
  )
  and ( exists ( "Two Influenza Vaccinations" )
      or ( "Two Influenza Vaccinations Including One LAIV Vaccination" )
      or exists ( "Influenza Numerator Inclusion Conditions" )
  )

Hepatitis A Numerator Inclusion Conditions
( ( ["Laboratory Test, Performed": "Anti Hepatitis A IgG Antigen Test"] HepatitisAAntigenTest
    where HepatitisAAntigenTest.result as Code in "Positive Finding"
)
  union ( ["Diagnosis": "Adverse reaction to vaccine product containing Hepatitis A virus antigen (disorder)"] HepatitisAReaction
      return "Laboratory Test, Performed" { relevantDatetime: start of HepatitisAReaction.prevalencePeriod }
  )
  union ( ["Diagnosis": "Hepatitis A"] HepatitisADiagnosis
      return "Laboratory Test, Performed" { relevantDatetime: start of HepatitisADiagnosis.prevalencePeriod }
  ) ) HepatitisAConditions
  where Global."NormalizeInterval" ( HepatitisAConditions.relevantDatetime, HepatitisAConditions.relevantPeriod ) during "First Two Years"

Influenza Numerator Inclusion Conditions
( ["Diagnosis": "Adverse reaction to vaccine product containing Influenza virus antigen (disorder)"]
  union ["Diagnosis": "Malignant Neoplasm of Lymphatic and Hematopoietic Tissue"]
  union ["Diagnosis": "Neomycin adverse reaction (disorder)"]
  union ["Diagnosis": "HIV"]
  union ["Diagnosis": "Disorders of the Immune System"] ) InfluenzaConditions
  where start of InfluenzaConditions.prevalencePeriod during "First Two Years"

MMR Numerator Inclusion Conditions
( ["Diagnosis": "Disorders of the Immune System"]
  union ["Diagnosis": "HIV"]
  union ["Diagnosis": "Malignant Neoplasm of Lymphatic and Hematopoietic Tissue"]
  union ["Diagnosis": "Neomycin adverse reaction (disorder)"] ) MMRConditions
  where ( start of MMRConditions.prevalencePeriod during Interval[Patient.birthDatetime, "Date of Second Birthday"])

Pneumococcal Conjugate Numerator Inclusion Conditions
["Diagnosis": "Adverse reaction to vaccine product containing Streptococcus pneumoniae antigen (disorder)"] PneumococcalReaction
  where start of PneumococcalReaction.prevalencePeriod during "First Two Years"

Polio Numerator Inclusion Conditions
( ["Diagnosis": "Adverse reaction to vaccine product containing Human poliovirus antigen (disorder)"]
  union ["Diagnosis": "Streptomycin adverse reaction (disorder)"]
  union ["Diagnosis": "Polymyxin B adverse reaction (disorder)"]
  union ["Diagnosis": "Neomycin adverse reaction (disorder)"] ) PolioConditions
  where start of PolioConditions.prevalencePeriod during "First Two Years"

Varicella Zoster Numerator Inclusion Conditions
( ( ["Laboratory Test, Performed": "Varicella Zoster Antibody Test (IgG Antibody Titer)"] ChickenPoxTiter
    where ChickenPoxTiter.result >= 1.10
)
  union ( ["Laboratory Test, Performed": "Varicella Zoster Antibody Test (IgG Antibody Presence)"] ChickenPoxIgGPresence
      where ChickenPoxIgGPresence.result as Code in "Positive Finding"
  )
  union ( ["Diagnosis": "Disorders of the Immune System"] ImmuneDisorder
      return "Laboratory Test, Performed" { relevantDatetime: start of ImmuneDisorder.prevalencePeriod }
  )
  union ( ["Diagnosis": "HIV"] HIV
      return "Laboratory Test, Performed" { relevantDatetime: start of HIV.prevalencePeriod }
  )
  union ( ["Diagnosis": "Malignant Neoplasm of Lymphatic and Hematopoietic Tissue"] LymphaticMalignantNeoplasm
      return "Laboratory Test, Performed" { relevantDatetime: start of LymphaticMalignantNeoplasm.prevalencePeriod }
  )
  union ( ["Diagnosis": "Neomycin adverse reaction (disorder)"] NeomycinReaction
      return "Laboratory Test, Performed" { relevantDatetime: start of NeomycinReaction.prevalencePeriod }
  )
  union ( ["Diagnosis": "Varicella Zoster"] VaricellaZoster
      return "Laboratory Test, Performed" { relevantDatetime: start of VaricellaZoster.prevalencePeriod }
  ) ) VaricellaZosterConditions
  where Global."NormalizeInterval" ( VaricellaZosterConditions.relevantDatetime, VaricellaZosterConditions.relevantPeriod ) ends during "First Two Years"

//Proposed logic:
Numerator
( exists ( "Four DTaP Vaccinations" )
    or exists ( "DTaP Numerator Inclusion Conditions" )
)
  and ( exists ( "Three Polio Vaccinations" )
      
  and ( exists ( "One MMR Vaccination" )
      or exists ( "MMR Numerator Inclusion Conditions" )
      or ( exists ( "Measles Indicators" )
          and exists ( "Mumps Indicators" )
          and exists ( "Rubella Indicators" )
      )
  )
  and ( "Has Appropriate Number of Hib Immunizations"
      or exists ( "Hib Numerator Inclusion Conditions" )
  )
  and ( exists ( "Three Hepatitis B Vaccinations" )
      or exists ( "Hepatitis B Numerator Inclusion Conditions" )
  )
  and ( exists ( "One Chicken Pox Vaccination" )
      or exists ( "Varicella Zoster Numerator Inclusion Conditions" )
  )
  and ( exists ( "Four Pneumococcal Conjugate Vaccinations" )
  )
  and ( exists ( "One Hepatitis A Vaccinations" )
      or exists ( "Hepatitis A Numerator Inclusion Conditions" )
  )
  and ( "Has Appropriate Number of Rotavirus Immunizations"
      or exists ( "Rotavirus Numerator Inclusion Conditions" )
  )
  and ( exists ( "Two Influenza Vaccinations" )
      or ( "Two Influenza Vaccinations Including One LAIV Vaccination" )
      or exists ( "Influenza Numerator Inclusion Conditions" )
  )

Hepatitis A Numerator Inclusion Conditions
( ( ["Laboratory Test, Performed": "Anti Hepatitis A IgG Antigen Test"] HepatitisAAntigenTest
    where HepatitisAAntigenTest.result as Code in "Positive Finding"
)
  union ( ["Diagnosis": "Hepatitis A"] HepatitisADiagnosis
      return "Laboratory Test, Performed" { relevantDatetime: start of HepatitisADiagnosis.prevalencePeriod }
  ) ) HepatitisAConditions
  where Global."NormalizeInterval" ( HepatitisAConditions.relevantDatetime, HepatitisAConditions.relevantPeriod ) during "First Two Years"

Influenza Numerator Inclusion Conditions
( union ["Diagnosis": "Malignant Neoplasm of Lymphatic and Hematopoietic Tissue"]
  union ["Diagnosis": "HIV"]
  union ["Diagnosis": "Disorders of the Immune System"] ) InfluenzaConditions
  where start of InfluenzaConditions.prevalencePeriod during "First Two Years"

MMR Numerator Inclusion Conditions
( ["Diagnosis": "Disorders of the Immune System"]
  union ["Diagnosis": "HIV"]
  union ["Diagnosis": "Malignant Neoplasm of Lymphatic and Hematopoietic Tissue"] ) MMRConditions
  where ( start of MMRConditions.prevalencePeriod during Interval[Patient.birthDatetime, "Date of Second Birthday"])

Varicella Zoster Numerator Inclusion Conditions
( ( ["Laboratory Test, Performed": "Varicella Zoster Antibody Test (IgG Antibody Titer)"] ChickenPoxTiter
    where ChickenPoxTiter.result >= 1.10
)
  union ( ["Laboratory Test, Performed": "Varicella Zoster Antibody Test (IgG Antibody Presence)"] ChickenPoxIgGPresence
      where ChickenPoxIgGPresence.result as Code in "Positive Finding"
  )

  union ( ["Diagnosis": "Disorders of the Immune System"] ImmuneDisorder
      return "Laboratory Test, Performed" { relevantDatetime: start of ImmuneDisorder.prevalencePeriod }
  )
  union ( ["Diagnosis": "HIV"] HIV
      return "Laboratory Test, Performed" { relevantDatetime: start of HIV.prevalencePeriod }
  )
  union ( ["Diagnosis": "Malignant Neoplasm of Lymphatic and Hematopoietic Tissue"] LymphaticMalignantNeoplasm
      return "Laboratory Test, Performed" { relevantDatetime: start of LymphaticMalignantNeoplasm.prevalencePeriod }
  )
  union ( ["Diagnosis": "Varicella Zoster"] VaricellaZoster
      return "Laboratory Test, Performed" { relevantDatetime: start of VaricellaZoster.prevalencePeriod }
  ) ) VaricellaZosterConditions
  where Global."NormalizeInterval" ( VaricellaZosterConditions.relevantDatetime, VaricellaZosterConditions.relevantPeriod ) ends during "First Two Years"

Rationale for Change:

​Currently, the measures use the QDM Diagnosis datatype and SNOMED (disorder) codes to represent adverse reactions to vaccine. After hearing concerns with this modeling approach from implementers, NCQA will remove adverse reaction criteria from CMS117 and CMS127 for 2023 performance period. We will explore new codes (severe reaction or anaphylaxis) and modeling approaches for the next year (2024 performance period during AU2023).