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  2. CQM-5605

CRP: Align description and numerator language with logic timing of macular exam

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    • Resolution: Unresolved
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      Brief description of measure:
      CMS142: ​Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
      Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months

      Description of issue:
      ​The description states "at least once within 12 months".  There is no logic to look at when the last communicated exam results occurred to verify an interval of 12 months (December to December, etc.). 

      The Numerator also indicates at least once within 12 months  but the logic assesses for a macular exam during the EncounterDiabeticRetinopathy that is during the measurement period. The description/narrative and logic should be in alignment.

      The numerator reads "Patients with documentation, at least once within 12 months, of the findings of the dilated macular or fundus exam via communication to the physician who manages the patient's diabetic care". However, the logic does not constrain  'Communication' to within 12 months or the measurement period,  of passing tests with communication 2 years after the encounter/exam. 

      Goal of review:
      Obtain clinical and technical feedback
      Show
      Brief description of measure: CMS142: ​Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months Description of issue: ​The description states "at least once within 12 months".  There is no logic to look at when the last communicated exam results occurred to verify an interval of 12 months (December to December, etc.).  The Numerator also indicates at least once within 12 months  but the logic assesses for a macular exam during the EncounterDiabeticRetinopathy that is during the measurement period. The description/narrative and logic should be in alignment. The numerator reads "Patients with documentation, at least once within 12 months, of the findings of the dilated macular or fundus exam via communication to the physician who manages the patient's diabetic care". However, the logic does not constrain  'Communication' to within 12 months or the measurement period,  of passing tests with communication 2 years after the encounter/exam.  Goal of review: Obtain clinical and technical feedback
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      Proposed solution:
      ​Align the description/narrative and logic by using this language: 'during the measurement period' in both.  

      Current Numerator: 
      Patients with documentation, at least once within 12 months, of the findings of the dilated macular or fundus exam via communication to the physician who manages the patient's diabetic care. 

      Proposed Numerator: 
      Patients with documentation, at least once within the reporting period, of the findings of the dilated macular or fundus exam via communication to the physician who manages the patient's diabetic care.

      Current Description: 
      Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months. 

      Proposed Description: 
      Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once during the reporting period.

      Rationale for change:
      Ensures alignment between the header and logic. The logic of the measure was always intended to fit into the reporting period.  

      This will also ensure that all eligible clinicians have to meet a specific cut-off timeframe by which the communication must occur to satisfy the numerator. 
      Show
      Proposed solution: ​Align the description/narrative and logic by using this language: 'during the measurement period' in both.   Current Numerator:  Patients with documentation, at least once within 12 months, of the findings of the dilated macular or fundus exam via communication to the physician who manages the patient's diabetic care.  Proposed Numerator:  Patients with documentation, at least once within the reporting period, of the findings of the dilated macular or fundus exam via communication to the physician who manages the patient's diabetic care. Current Description:  Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months.  Proposed Description:  Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once during the reporting period. Rationale for change: Ensures alignment between the header and logic. The logic of the measure was always intended to fit into the reporting period.   This will also ensure that all eligible clinicians have to meet a specific cut-off timeframe by which the communication must occur to satisfy the numerator. 

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          edave Mathematica EC eCQM Team
          edave Mathematica EC eCQM Team
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