​Thank you for your inquiry regarding CMS156v11, Use of High Risk Medications in Older Adults (2023 Performance Period). The high-risk medications for Numerator rate 1a, rate 1b, and rate 1c are not all the same or subsets of each other. Complete lists of medications for each criteria can be viewed in the logic and terminology sections of the eCQM Human-Readable HTML format ( https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS156v11-v2.html ). Please find respective specifications of Numerator rate 1a, rate 1b, and rate 1c below. For example, high-risk medications for Numerator rate 1a would include medications listed under the CQL definition "Same High Risk Medications Ordered on Different Days", i.e., RxNorm code 197622 listed in the value set "Antithrombotic" (2.16.840.1.113883.3.464.1003.1051). Similarly, Numerator rate 1b and rate 1c are represented by CQL definitions "Two High Risk Medications with Prolonged Duration" and "High Risk Medications with Average Daily Dose Criteria", respectively. For more assistance on reading eCQM specifications, you may refer to the following "Guide for Reading eCQMs” available on the eCQI Resource Center: https://ecqi.healthit.gov/sites/default/files/Guide-for-Reading-eCQMs-v8.pdf . For your second question, the measure defines an order in the "Definition" section of the eCQM header as such: "an order is identified by either a prescription order or a prescription refill." Therefore, "two orders on different days" can be interpreted as two orders during the measurement period on different days, or an order during the measurement with at least one refill. This guidance is further specified in the CQL function, “More Than One Order”, as included below. Numerator exists ( "Same High Risk Medications Ordered on Different Days" ) or ( "Two High Risk Medications with Prolonged Duration" ) or ( "High Risk Medications with Average Daily Dose Criteria" ) Same High Risk Medications Ordered on Different Days "More Than One Order"(["Medication, Order": "Anticholinergics, first generation antihistamines"]) union "More Than One Order"(["Medication, Order": "Anticholinergics, anti Parkinson agents"]) union "More Than One Order"(["Medication, Order": "Antispasmodics"]) union "More Than One Order"(["Medication, Order": "Antithrombotic"]) union "More Than One Order"(["Medication, Order": "Cardiovascular, alpha agonists, central"]) union "More Than One Order"(["Medication, Order": "Cardiovascular, other"]) union "More Than One Order"(["Medication, Order": "Central nervous system, antidepressants"]) union "More Than One Order"(["Medication, Order": "Central nervous system, barbiturates"]) union "More Than One Order"(["Medication, Order": "Central nervous system, vasodilators"]) union "More Than One Order"(["Medication, Order": "Central nervous system, other"]) union "More Than One Order"(["Medication, Order": "Endocrine system, estrogens with or without progestins"]) union "More Than One Order"(["Medication, Order": "Endocrine system, sulfonylureas, long duration"]) union "More Than One Order"(["Medication, Order": "Endocrine system, other"]) union "More Than One Order"(["Medication, Order": "Nonbenzodiazepine hypnotics"]) union "More Than One Order"(["Medication, Order": "Pain medications, skeletal muscle relaxants"]) union "More Than One Order"(["Medication, Order": "Pain medications, other"]) Two High Risk Medications with Prolonged Duration Sum(("More Than One Order"(["Medication, Order": "Anti Infectives, other"]))AntiInfectives let DaysSupply: Coalesce(AntiInfectives.daysSupplied, AntiInfectives.supply.value /(AntiInfectives.dosage.value * CMD.ToDaily(AntiInfectives.frequency)))*(1 + Coalesce(AntiInfectives.refills, 0)) return all DaysSupply )> 90 High Risk Medications with Average Daily Dose Criteria exists ( "More Than One Order"(["Medication, Order": "Reserpine"] ReserpineOrdered where "Average Daily Dose"(ReserpineOrdered)> 0.1 'mg/d' ) ) or exists ( "More Than One Order"(["Medication, Order": "Digoxin"] DigoxinOrdered where "Average Daily Dose"(DigoxinOrdered)> 0.125 'mg/d' ) ) or exists ( "More Than One Order"(["Medication, Order": "Doxepin"] DoxepinOrdered where "Average Daily Dose"(DoxepinOrdered)> 6 'mg/d' ) ) More Than One Order(Medication List<"Medication, Order">) "Medication" OrderMedication1 with "Medication" OrderMedication2 such that ( OrderMedication1.authorDatetime during "Measurement Period" and OrderMedication1.refills >= 1 ) or ( date from OrderMedication1.authorDatetime !~ date from OrderMedication2.authorDatetime and OrderMedication1.authorDatetime during "Measurement Period" and OrderMedication2.authorDatetime during "Measurement Period" ) return OrderMedication1

I have a question about the eCQM measure specifications for MIPS 238: Use of High Risk Medications in Older Adults. For the numerator, Rate 1 is described as the following: Rate 1: Patients with at least two orders of high-risk medications from the same drug class on different days. a. At least two orders of high-risk medications from the same drug class. b. At least two orders of high-risk medications from the same drug class with summed days supply greater than 90 days. c. At least two orders of high-risk medications from the same drug class each exceeding average daily dose criteria. It appears that for "a", this includes all patients that would also be included in the subsets, "b" and "c". For example, if a patient meets the denominator criteria, then we would assess "a"- the patient has at least two orders of high-risk medications from the same drug class. If this statement is true, then the patient would meet the numerator criteria for Rate 1 without further assessment for "b" or "c". Can you please confirm that we are thinking about this correctly? Also, for 2023 the measure specification language was updated to specify for Rate 1 and Rate 2 that at least two orders for high risk medications from the same drug class were “ordered on different days”. This indicates that if two high risk medications from the same drug class were ordered on the SAME DAY, then it would not meet the numerator. Is this correct?