Performance Measurement in the Hospital Outpatient Setting. Appendix D: Measures Potentially Relevant to the Hospital Outpatient Setting and Emergency Department

02/01/2008

Measure Specialties Source of Measure Included in PQRI as of 6/1/07
Prevention/Screening:      
Breast Cancer Screening*+ PC¹, OB/GYN CMS/NCQA, AMA/PCPI, ICSI, ACOVE²  
Colorectal Cancer Screening*+ PC, Gastroenterology NCQA, AMA/PCPI, ICSI, ACOVE  
Colonoscopy: Procedure Complication Rate Gastroenterology Accreditation Assoc for Ambulatory Health Care (AAAHC)  
Colonoscopy: Patient Understanding of Procedure Gastroenterology AAAHC  
Colonoscopy-Polyp Surveillance: Cecal Intubation Documentation Gastroenterology American Gastroenterological Assoc Institute (AGAI)  
Colonoscopy-Polyp Surveillance: Rate of Cecal Intubation Gastroenterology AGAI  
Colonoscopy-Polyp Surveillance: Preparation Adequacy Documentation Gastroenterology AGAI  
Colonoscopy-Polyp Surveillance: Rate of Preparation Adequacy Gastroenterology AGAI  
Colonoscopy-Polyp Surveillance: Description of Polyp Characteristics Gastroenterology AGAI  
Colonoscopy-Polyp Surveillance: Assessment of Polyp Removal Gastroenterology AGAI  
Colonoscopy-Polyp Surveillance: Pathology Results Present and Reviewed Gastroenterology, Pathology AGAI  
Colonoscopy-Polyp Surveillance: Appropriateness of Follow-up Interval Recommended Gastroenterology AGAI  
Colonoscopy-Polyp Surveillance: Communication of Results and Follow-up Interval to PCP Gastroenterology AGAI  
Colonoscopy-Polyp Surveillance: Communication of Results and Follow-up Interval to Referral Source Gastroenterology AGAI  
Colonoscopy-Polyp Surveillance: Communication of Results and Follow-up Interval to the Patient Gastroenterology AGAI  
Colonoscopy: Abdominal Pain Within 30 Days Gastroenterology Wynn et al  
Colonoscopy: Hemorrhage Within 30 Days Gastroenterology Wynn et al  
Colonoscopy: Chest Pain Within 30 Days Gastroenterology Wynn et al  
Colonoscopy: Dyspnea Within 30 Days Gastroenterology Wynn et al  
Colonoscopy: Small Bowel Obstruction Within 30 Days Gastroenterology Wynn et al  
Colonoscopy: Arrythmia Within 30 Days Gastroenterology Wynn et al  
Colonoscopy: Vasovagal Reactions Within 30 Days Gastroenterology Wynn et al  
Colonoscopy: Sepsis and Other Infections Within 30 Days Gastroenterology Wynn et al  
Colonoscopy: Abdominal Distention Within 30 Days Gastroenterology Wynn et al  
Colonoscopy: Other Complications Within 30 Days Gastroenterology Wynn et al  
Colonoscopy: Hypotension Within 30 Days Gastroenterology Wynn et al  
Colonoscopy: Perforation Within 30 Days Gastroenterology Wynn et al  
Colonoscopy: Splenic Rupture Within 30 Days Gastroenterology Wynn et al  
Colonoscopy: Altered Mental Status Within 30 Days Gastroenterology Wynn et al  
Colonoscopy: Endocarditis Within 30 Days Gastroenterology Wynn et al  
Colonoscopy: Hypoxia Within 30 Days Gastroenterology Wynn et al  
Colonoscopy: Hypertension Within 30 Days Gastroenterology Wynn et al  
Colonoscopy: Death Within 1 Week Gastroenterology Wynn et al  
Cervical Cancer Screening*+ PC, OB/GYN NCQA, ICSI, ACOVE  
Avoid Pap Smear After Hysterectomy PC, OB/GYN ACOVE  
Follow up of Abnormal Pap Smear PC, OB/GYN ICSI, RAND  
Tobacco Use Assessment and Cessation*+ PC, OB/GYN AMA/PCPI, ICSI, ACOVE  
Smoking Cessation-Medical Assistance*+ PC, OB/GYN, Specialists NCQA, ACOVE  
Influenza Vaccination (50-64)*+ PC NCQA, AMA/PCPI, ICSI,  
Influenza Vaccination (65+)* PC CMS/NCQA, AMA/PCPI, ICSI, ACOVE  
Pneumonia Vaccination*+ PC NCQA, AMA/PCPI, ICSI, Resolution Health, ACOVE  
Tetanus-Diphtheria Booster PC ACOVE  
Drugs to be Avoided in the Elderly* PC NCQA, ACOVE  
Potentially Harmful Drug-Disease Interactions in the Elderly PC NCQA, ACOVE  
Annual Monitoring for Patients on Persistent Medications*+ PC NCQA, ACOVE  
Medication Reconciliation for Elderly (Care Coordination)+ PC AMA/PCPI, ACOVE X
Documentation of Allergies and Adverse Reactions in Outpatient Medical Record* PC CMS/SCRIPT X
Documentation of Medication List in the Outpatient Record* PC CMS/SCRIPT, ACOVE  
Advance Care Planning for Elderly+ PC AMA/PCPI, ACOVE X
Screening for Fall Risk*+ PC AMA/PCPI, ACOVE X
Screen for Problem Drinking PC AMA/PCPI, ACOVE  
Counseling for Problem Drinking PC ACOVE  
Counseling on Physical Activity in Older Adults* PC NCQA, ACOVE  
Obesity: BMI Documentation* PC NYC-DHMH, ACOVE  
Prevention and Management of Obesity PC ICSI, ACOVE  
Depression Screening for Older Adults PC ACOVE  
Osteoporosis Screening for Women (65+)* PC, Orthopedics, Rheumatology, Endocrinology NCQA, AMA/PCPI, ICSI, ACOVE X
Osteoporosis Screening for Men with Risk Factors PC ACOVE  
Screening for Persistent Pain PC ACOVE  
Hormone Replacement Therapy: Risks and Benefits PC, OB/GYN ACOVE  
Screening for Elder Abuse PC ACOVE  
Comprehensive Geriatrics Assessment PC ACOVE  
Comprehensive Eye Exam PC, Ophthalmology ACOVE  
Cognitive and Functional Screening PC ACOVE  
Annual Evaluation for Changes in Memory, Function PC ACOVE  
Annual Evaluation of Hearing Status PC ACOVE  
Annual Screening for Sleep Disorders PC ACOVE  
Allergies/Sinus:      
Rhinitis: Prophylactic Medication PC, Immunology, ENT, Pulmonology ICSI  
Acute Sinusitis: Sinus X-Ray After Initial Visit PC, Immunology, ENT, Pulmonology ICSI  
Acute Sinusitis: First Line Antibiotic When an Antibiotic is Prescribed PC, Immunology, ENT, Pulmonology ICSI  
Ambulatory Surgery:      
Patients Having a Preoperative Health Assessment and Any Adjunctive Evaluation Prior to Scheduled Procedure All Surgery, PC, Anesthesiology ICSI, ACOVE  
Capacity to Consent to Surgery All Surgery, PC ACOVE  
Preoperative Discussion All Surgery ACOVE  
Preoperative Diabetes Evaluation All Surgery, PC ACOVE  
Preoperative Delirium Assessment All Surgery, PC ACOVE  
Timing of Prophylactic Antibiotic-Ordering Physician+ General, Orthopedic, Colorectal, Hand, Plastic, Thoracic, Vascular AMA/PCPI X
Timing of Prophylactic Antibiotic-Administering Physician+ Anesthesiology, All Surgery AMA/PCPI X
Antibiotic Selection+ General, Orthopedic, Colorectal, Hand, Plastic, Thoracic, Vascular AMA/PCPI X
Antibiotic Discontinuation within 24 Hours+ General, Orthopedic, Colorectal, Hand, Plastic, Thoracic, Vascular AMA/PCPI X
Venous Thromboembolism Prophylaxis*+ General, Orthopedic, Colorectal, Hand, Plastic, Thoracic, Vascular AMA/PCPI X
Selection of IV Antibiotic Administration All Surgery CMS  
Behavioral Health:      
Follow-up After Hospitalization for Mental Illness Psychiatry, PC NCQA, ICSI, ACOVE  
Major Depressive Disorder: Diagnostic Evaluation* Psychiatry AMA/PCPI, ACOVE  
Major Depressive Disorder: Suicide Risk Assessment* Psychiatry, PC AMA/PCPI, ACOVE  
New Episode of Depression: Evaluate for Co-Morbid Conditions Psychiatry, PC ACOVE  
New Episode of Depression: Optimal Practitioner Contacts for Medication Management* Psychiatry, PC NCQA  
Depression: Acute Phase Treatment*+ Psychiatry, PC NCQA X
Depression: Continuation Phase Treatment*+ Psychiatry, PC NCQA, AMA/PCPI  
Depression: Severity Classification Psychiatry AMA/PCPI  
Depression Treatment: Psychotherapy, Medication Management, and/or ECT Psychiatry, PC AMA/PCPI, ACOVE  
Depression: Antidepressant Choice Psychiatry, PC ACOVE  
Depression: Psychotic Depression Treatment Psychiatry ACOVE  
Depression: ECG for Tricyclic Use Psychiatry, PC ACOVE  
Depression: Interactions with MAOI Psychiatry, PC ACOVE  
Depression: Follow-up- Response and Medication Side Effects Documented Psychiatry, PC ACOVE  
Depression: Follow-up — Suicide Risk Psychiatry, PC ACOVE  
Depression: Follow-up 6 Weeks-No Symptom Response Psychiatry, PC ACOVE  
Depression: Follow-up 12 Weeks-Partial Response Psychiatry, PC ACOVE  
Depression: Continuing Therapy Psychiatry, PC ACOVE  
Depression: Maintenance Therapy Psychiatry, PC ACOVE  
Depression: Patients who Attain a 5 Point or Greater Reduction in Patient Health Questionnaire (PHQ) Score Within 6 Months After Their New Episode PHQ Psychiatry, PC Heath Resources and Services Administration (HRSA)  
Depression: Documented PHQ Reassessment Between 4-8 Weeks After New Episode PHQ Psychiatry, PC HRSA  
Depression: Follow up 1-3 Weeks After New Episode PHQ Psychiatry, PC HRSA  
Depression: Antidepressant and/or Psychotherapy Within 1 Month of Last New Episode PHQ. Psychiatry, PC HRSA  
Depression: 50% or Greater Reduction in PHQ 4 Months or Longer After Last New Episode PHQ Psychiatry, PC HRSA  
Depression: PHQ Score < 5, 4 Months or Longer After Last New Episode PHQ Psychiatry, PC HRSA  
Depression: Patients With a Diagnosis of Minor Depression, Depression NOS, or Adjustment Disorder Who Are Not on an Antidepressant Psychiatry, PC HRSA  
Depression: Diagnosis of Depression and a PHQ Score Within Last 6 Months Psychiatry, PC HRSA  
Depression: Patients Reporting an Improvement in Function Psychiatry, PC HRSA  
Depression: Documented Self-Management Goals Set Within Last 12 Months Psychiatry, PC HRSA  
Depression: Patients With a Diagnosis of Major Depression or Dysthymia Taking an Antidepressant Psychiatry, PC HRSA  
Depression: Patients With a Diagnosis of Major Depression or Dysthymia Who Have Been on an Antidepressant for At Least 6 Mos Psychiatry, PC HRSA  
Bipolar Disorder and Major Depression: Assessment for Manic or Hypomanic Behaviors* Psychiatry STABLE Project  
Bipolar Disorder and Major Depression: Appraisal for Alcohol or Chemical Substance Abuse* Psychiatry STABLE Project  
Bipolar Disorder: Appraisal for Risk of Suicide* Psychiatry STABLE Project  
Bipolar Disorder: Level of Function Evaluation* Psychiatry STABLE Project  
Bipolar Disorder: Assessment for Diabetes* Psychiatry, PC STABLE Project  
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment* Psychiatry, PC NCQA  
Dementia: Cognitive Evaluation PC, Neurology ACOVE  
Dementia: Medication Review PC, Neurology ACOVE  
Dementia: Medication Changes PC, Neurology ACOVE  
Dementia: Neurologic Examination PC, Neurology ACOVE  
Dementia: Laboratory Testing PC, Neurology ACOVE  
Dementia: HIV Testing PC, Neurology ACOVE  
Dementia: Depression Screening PC, Psychiatry, Neurology ACOVE  
Dementia: Alzheimer’s, Vascular Dementia, Lewy Body Dementia- Medication Discussion PC, Neurology ACOVE  
Dementia: Moderate Vascular or Mixed Dementia- Stroke Prophylaxis PC, Neurology ACOVE  
Dementia: Caregiver Support and Patient Safety PC, Neurology ACOVE  
Dementia: Behavioral/Psychological Symptoms PC, Psychiatry ACOVE  
Dementia: Behavioral Interventions and Pharmacotherapy Psychiatry, Neurology ACOVE  
Dementia: Antipsychotic Risk/Benefit Discussion Psychiatry, Neurology ACOVE  
Dementia: Driving PC, Psychiatry, Neurology ACOVE  
Bone and Joint Conditions:      
Osteoporosis Management in Women Who Had a Fracture* PC, Orthopedics, Rheumatology, Endocrinology NCQA,AMA/PCPI, ACOVE X
Osteoporosis: Communication with Physician Managing* Care Post Fracture Ortho, Rheumatology, Endocrinology, AMA/PCPI X
Osteoporosis: Pharmacologic Therapy-Female* PC, OB/Gyn, Orthopedics, Rheumatology, Endocrinology AMA/PCPI, ACOVE X
Osteoporosis Pharmacologic Therapy for Males PC, Orthopedics, Rheumatology, Endocrinology ACOVE  
Osteoporosis: Testosterone for Males PC, Orthopedics, Rheumatology, Endocrinology ACOVE  
Osteoporosis: Counseling for Vitamin D, Calcium Intake, Exercise PC, Orthopedics, Rheumatology, Endocrinology AMA/PCPI, ACOVE X
Osteoporosis: DXA Measurement for Glucocorticosteroids and Other Secondary Causes PC, Orthopedics, Rheumatology, Endocrinology AMA/PCPI  
Osteoporosis: Prophylaxis for Steroids PC, Orthopedics, Rheumatology, Endocrinology ACOVE  
Osteoarthritis: Functional and Pain Assessment* PC, Orthopedics, Rheumatology AMA/PCPI, ACOVE  
Osteoarthritis: Physical Examination of the Involved Joint PC, Orthopedics, Rheumatology AMA/PCPI  
Osteoarthritis: Assessment for OTC Medications* PC, Orthopedics, Rheumatology AMA/PCPI, ACOVE  
Osteoarthritis: Anti-inflammatory/Analgesic Therapy PC, Orthopedics, Rheumatology AMA/PCPI  
Osteoarthritis: NSAID Risk Assessment PC, Orthopedics, Rheumatology AMA/PCPI  
Osteoarthritis: Gastrointestinal Prophylaxis PC, Orthopedics, Rheumatology AMA/PCPI  
Osteoarthritis: Therapeutic Exercise for the Involved Joint PC, Orthopedics, Rheumatology AMA/PCPI, ICSI, ACOVE  
Osteoarthritis: Patient Education PC, Orthopedics, Rheumatology Arthritis Foundation  
Osteoarthritis: Radiograph For Worsening Condition PC, Orthopedics, Rheumatology Arthritis Foundation  
Osteoarthritis: Referral to Orthopedic Surgeon PC, Rheumatology Arthritis Foundation, ACOVE  
Osteoarthritis: Advised to Lose Weight PC, Orthopedics, Rheumatology Arthritis Foundation  
Osteoarthritis: Referred to Weight Loss Program PC, Orthopedics, Rheumatology Arthritis Foundation  
Osteoarthritis: Ambulatory Assistive Devices PC, Orthopedics, Rheumatology Arthritis Foundation, ACOVE  
Osteoarthritis: Non-Ambulatory Assistive Devices PC, Orthopedics, Rheumatology Arthritis Foundation, ACOVE  
Degenerative Joint Disease (DJD) of the Knee: X-Rays Including a Standing View of the Knee PC, Orthopedics, Rheumatology ICSI  
DJD of the Knee: Documented Education on Protecting the Joint, Exercise, Pain Relief, Healthy Habits PC, Orthopedics, Rheumatology ICSI  
Use of Imaging Studies for Low Back Pain* PC, Orthopedics, Radiology NCQA, ICSI  
Relative Resource Use for Acute Low Back Pain PC, Orthopedics, Rheumatology Radiology NCQA  
Arthritis: Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis* Rheumatology NCQA  
Ankle Sprain: X-Rays Within 3 Days of Initial Injury PC ICSI  
Ankle Sprain: Documentation of Patient Education PC ICSI  
Change in Foot/Ankle Functional Status PT Focus on Treatment Outcomes (FOTO)  
Change in Hip Functional Status PT FOTO  
Change in Knee Functional Status PT FOTO  
Change in Lumbar Functional Status PT FOTO  
Change in Physical Functional Status PT FOTO  
Change in Shoulder Functional Status PT FOTO  
Cancer-Blood:      
Myelodyplastic Syndrome (MDS): Cytogenetic Testing on Bone Marrow+ Hematology, Oncology AMA/PCPI X
MDS: Iron Stores Prior to Erythropoietin Therapy+ Hematology, Oncology AMA/PCPI X
Multiple Myloma: Treatment with Biophosphonates+ Hematology, Oncology AMA/PCPI X
Chronic Lymphocytic Leukemia: Baseline Flow Cytometry+ Hematology, Oncology AMA/PCPI X
Non Hodgkin’s Lymphoma (Aggressive): White Blood Cell Colony Stimulating Factors for Patients >60 Undergoing Chemotherapy Hematology, Oncology ASSIST  
Cancer-Breast:      
Diagnosis: Average Number of Days Between Breast Abnormality and Biopsy PC, OB-GYN, Radiology, Oncology ICSI  
Diagnosis: Class 4-5 Abnormal Mammograms Followed by a Biopsy Within 14 Days PC, OB/GYN, Oncology ICSI  
Patients with Stage 0, I, II or III Breast Cancer With Documentation of Discussion of Clinical Trials Oncology ICSI  
Hormonal Therapy for Stage IC-III , ER/PR Positive Breast Cancer *+ Oncology National Cancer Care Network/American Society of Clinical Oncology (NCCN/ASCO), ACOVE X
Radiation Therapy for Invasive Breast Cancer Patients Who Have Undergone Breast Conserving Therapy* + Oncology, Radiation Oncology NCCN/ASCO, ACOVE X
Patients < 70 with Stage II-III Breast Cancer Receiving Adjuvant Chemo within 120 Days After Diagnosis* Oncology NCCN/ASCO  
Trastuzumab Administration for Her2Neu Positive Patients Oncology NCCN/ASCO  
Biphosphonates for Patients with Bone Metastases Oncology NCCN/ASCO, ACOVE  
Creatinine Assessed for Patients Receiving Biphosphonates Oncology NCCN/ASCO  
Resection Pathology Report Includes the pT Category and Histologic Grade Pathology AMA/PCPI  
Breast Cancer Diagnosis: History-Physical and Psychosocial Performance Status Surgery, Oncology ACOVE  
Breast Cancer Diagnosis: History-Co-morbid Illnesses Surgery, Oncology ACOVE  
Breast Cancer Diagnosis: Discussion of Options Surgery, Oncology ACOVE  
Breast Cancer Diagnosis: Surgical Documentation Surgery ACOVE  
Breast Cancer Diagnosis: Estrogen Receptor Status Documented Surgery, Pathology ACOVE  
Breast Cancer Diagnosis: HER-2/neu Receptor Status Documented Surgery, Pathology ACOVE  
Breast Cancer Diagnosis: HER-2/neu Receptor Status Confirmed Surgery, Pathology ACOVE  
Breast Cancer Diagnosis: Bone Evaluation Oncology ACOVE  
Breast Cancer Diagnosis: Surgical Care- Axillary Staging Surgery ACOVE  
Breast Cancer Diagnosis: Surgical Care-Lobular Carcinoma In-Situ Surgery ACOVE  
Breast Cancer Diagnosis: Surgical Care-DCIS Surgery ACOVE  
Breast Cancer Diagnosis: Surgical Care-Mastectomy, Breast Reconstruction Surgery ACOVE  
Breast Cancer Diagnosis: Radiation Therapy-Lumpectomy Oncology, Radiation Oncology ACOVE  
Breast Cancer Diagnosis: Radiation Therapy-Mastectomy Oncology, Radiation Oncology ACOVE  
Breast Cancer Diagnosis: Adjuvant Chemotherapy Oncology ACOVE  
Breast Cancer Diagnosis: Adjuvant Chemotherapy and Trastuzumab Oncology ACOVE  
Breast Cancer Diagnosis: Treatment-Limited Surveillance Oncology ACOVE  
Breast Cancer Diagnosis: Metastatic Disease-Endocrine Therapy Oncology ACOVE  
Breast Cancer Diagnosis: Metastatic Disease-Chemotherapy Offered Oncology ACOVE  
Breast Cancer Diagnosis: Metastatic Disease-Trastuzumab Offered Oncology ACOVE  
Nausea and Vomiting-3-Drug Regimen Post Chemotherapy of Moderate Acute and Delayed Emetic Risk Oncology ASSIST  
Cancer-Colorectal:      
Post Operative Adjuvant Chemo Within 9 Months After Diagnosis of Stage II-III Rectal Cancer Oncology, Surgery/Colorectal Surgery NCCN/ASCO  
Pelvic Radiation Therapy Before or After Surgery for Stage II-III Rectal Cancer Oncology, Surgery/Colorectal Surgery NCCN/ASCO  
Chemotherapy for Stage III Colon Cancer Patients w/in 4 mos *+ Oncology, Surgery/Colorectal Surgery NCCN/ASCO, ACOVE X
Carcinoembryonic Antigen (CEA) Assessed for Colon and Rectal Cancers Oncology, Surgery/Colorectal Surgery ASCO, ACOVE  
Chemotherapy Recommended Appropriately for Colon and Rectal Cancers Oncology, Surgery/Colorectal Surgery ASCO  
Colorectal Cancer Pathology Reporting: pT Category and pN Category with Histologic Grade Pathology AMA/PCPI  
History-Physical and Psychosocial Status Surgery/Colorectal Surgery ACOVE  
History-Co-Morbid Illness Surgery/Colorectal Surgery ACOVE  
Staging Evaluation-CT scan Surgery/Colorectal Surgery ACOVE  
Staging Evaluation-Ultrasound, MRI or CT Surgery/Colorectal Surgery ACOVE  
Colon Examination Prior to Surgery Surgery/Colorectal Surgery ACOVE  
Colon Exam After Surgery Surgery/Colorectal Surgery ACOVE  
Discussion of Options Surgery/Colorectal Surgery, Oncology ACOVE  
Discussion of Surgical Findings Surgery/Colorectal Surgery, Oncology ACOVE  
Non-Surgical Treatment Plan Surgery/Colorectal Surgery, Oncology ACOVE  
Preoperative Exam Surgery/Colorectal Surgery ACOVE  
Preoperative Ostomy Sitting Surgery/Colorectal Surgery ACOVE  
Adjuvant Therapy: Preoperative Neoadjuvant Chemotherapy and/or Radiation Oncology, Radiation Oncology ACOVE  
Post-Operative Surveillance: History and Physical Exam Surgery/Colorectal Surgery, PC, Oncology ACOVE  
Post-Operative Surveillance: CEA Level Oncology, PC ACOVE  
Post-Operative Surveillance: Colonoscopy Oncology, PC ACOVE  
Post-Operative Surveillance: Evaluate Rising CEA Oncology, PC ACOVE  
Cancer-Head and Neck:      
Mucositis: Midline Radiation Blocks and Three Dimensional Treatments for Patients Undergoing Radiation Radiation Oncology ASSIST  
Cancer-Lung:      
Dyspnea: Symptom Management or Treatment Oncology ASSIST  
Cancer-Prostate:      
Number of Patients a Physician Has Treated Urology, Oncology Litwin et al  
Availability of Radiation Oncology Facilities and Psychological Counseling for Patients Urology, Oncology, Radiation Oncology Litwin et al  
Board Certification of Urologist and Radiation Oncologists Urology, Oncology, Radiation Oncology Litwin et al  
Information About Outcomes for Patients Treated by an Institution Urology, Oncology, Radiation Oncology Litwin et al  
Assess Stage of Disease Before Treatment Begins Urology, Oncology, Radiation Oncology Litwin et al  
Document Pre-Treatment Urinary, Sexual and Bowel Function Urology, Oncology, Radiation Oncology Litwin et al  
Assess Family History of Prostate Cancer Urology, Oncology, Radiation Oncology Litwin et al  
Give Treatment Choices, Opportunity for Consultation, Description of Risk Urology, Oncology, Radiation Oncology Litwin et al  
Management of Pathology Specimens Pathology Litwin et al  
Use of Computerized Tomography to Plan Treatment Oncology, Radiation Oncology Litwin et al  
Immobilizing Patient During Treatment Oncology, Radiation Oncology Litwin et al  
Delivering Recommended Doses of Radiation Oncology, Radiation Oncology Litwin et al  
Follow-up After Treatment Oncology, Urology, Radiation Oncology Litwin et al  
Communicating with PCP Urology, Oncology, Radiation Oncology Litwin et al  
Treatment Failure Detected by Biochemical Tests Urology, Oncology, Radiation Oncology Litwin et al  
Hospitalization or Medical or Surgical Treatment for Serious Complications Urology, Oncology, Radiation Oncology Litwin et al  
Patients’ Assessment of Urinary, Sexual and Bowel Functioning After Treatment Urology, Oncology, Radiation Oncology Litwin et al  
Patient’s Satisfaction with Treatment Choice, Continence, and Potency Urology, Oncology, Radiation Oncology Litwin et al  
Cancer-General:      
Pathology Report in the Chart Oncology ASCO  
Staging Documented Oncology ASCO  
Clinical Trials Assessment Oncology ASCO  
Pain Assessment on First Visit Oncology ASCO, ACOVE, ASSIST  
Treatment of Severe Pain Oncology ACOVE, ASSIST  
Effectiveness of Pain Medication Assessed After Prescription Oncology ASCO, ASSIST  
Documented Plan for Chemotherapy+ Oncology ASCO X
Flow Sheet for Chemotherapy Oncology ASCO  
Consent for Chemotherapy in Chart Oncology ASCO  
Creatinine Assessed For Patients Receiving Cisplatin Oncology ASCO  
Chemotherapy-Related Documentation and Patient Discussions Oncology ASCO, ASSIST  
Smoking Cessation Oncology ASCO  
Monthly Patient Evaluation Oncology ASCO  
Administration of Entiemetic Medications Oncology ASCO, ASSIST  
Erythroid Growth Factor Administration Oncology ASCO  
Comfortable Dying* Oncology, PC, Palliative Care National Hospice and Palliative Care Org (NHPCO)  
Family Evaluation of Hospice Care * Hospice Provider, Palliative Care NHPCO  
ER Visits in Last 30 Days of Life Oncology, PC Dana Farber Cancer Institute (DFCI)  
Hospitalizations in the Last 30 Days of Life* Oncology, PC DFCI  
ICU Admission in the Last 30 Days of Life* Oncology, PC DFCI  
Not Admitted to Hospice* Oncology, PC DFCI  
Admitted to Hospice for < 3 Days * Oncology, PC DFCI  
Death in an Acute Care Setting* Oncology, PC DFCI  
Pain: Assess Likely Etiology Oncology, PC ASSIST  
Pain: Assessment of Functional Impairment Oncology, PC ASSIST  
Pain: Education if Starting Pharmacologic Treatment Oncology, PC ASSIST  
Pain: Long-Acting and Short Acting Opioids Oncology, PC ASSIST  
Pain: Bowel Regimen if Chronic Opioid Treatment Oncology, PC ASSIST  
Pain: Dose of Opioids Across Care Settings Oncology, PC ASSIST  
Pain: Change in Pain Regimen for Severe or Worsening Pain Oncology, PC ASSIST  
Pain: Changes in Regimen Assessed at Next Visit Oncology, PC ASSIST  
Pain: Single Fraction Radiation For Bone Metastasis Oncology, PC ASSIST  
Pain: Steroids for Spinal Cord Compression Oncology, PC ASSIST  
Pain: MRI for New Neurological Symptoms or Potential Spinal Chord Compression Oncology, PC ASSIST  
Pain: Radiotherapy or Surgical Decompression Within 24 Hours for Confirmed Spinal Chord Compression Oncology, PC ASSIST  
Pain: Follow-up Neurologic Symptoms After Treatment for Spinal Chord Compression Oncology, PC ASSIST  
Depression: Screen Within One Month of Diagnosis Oncology, PC ASSIST  
Depression: Screen for Newly Diagnosed Patients Undergoing Chemotherapy or Radiotherapy Oncology, PC ASSIST  
Depression: Treatment Plan Oncology, PC ASSIST  
Depression: Response to Therapy Documented Within 6 Weeks Oncology, PC ASSIST  
Depression: Assess if Expression of Desire for Hastened Death Oncology, PC ASSIST  
Nausea and Vomiting: Assess at Every Visit if Chemotherapy or Advanced Cancer Affection Gastrointestinal Tract or Abdomen Oncology, PC ASSIST  
Nausea and Vomiting: 3-Drug Regimen Prior to Chemotherapy With High Acute Emetic Risk Oncology, PC ASSIST  
Nausea and Vomiting: 2-Drug Regimen Post Chemotherapy With a High Delayed Emetic Risk Oncology, PC ASSIST  
Nausea and Vomiting: 2-Drug Regimen Prior to Chemotherapy With a Moderate Acute Emetic Risk Oncology, PC ASSIST  
Nausea and Vomiting: 5-HT3 Receptor Antagonist or Dexamethasone Post Chemotherapy With a Moderate Delayed Emetic Risk Oncology, PC ASSIST  
Nausea and Vomiting: Post-Chemotherapy Communication Plan for High to Moderately Emetic Chemotherapy Regimen Oncology, PC ASSIST  
Nausea and Vomiting: Assess for Underlying Causes if no Chemotherapy or Radiation Oncology, PC ASSIST  
Nausea and Vomiting: Evaluate Treatment With Antiemetic Medication Before or on Next Visit Oncology, PC ASSIST  
Fatigue: Assessment of Fatigue if Undergoing Chemotherapy Oncology, PC ASSIST  
Fatigue: Assessment of Fatigue if New Diagnosis of Advanced Cancer Oncology, PC ASSIST  
Fatigue: Assessment for Insomnia or Depression if New Fatigue Oncology, PC ASSIST  
Fatigue: Assessment For Response to Treatment Oncology, PC ASSIST  
Anemia: Assess Presence or Absence of Anemia-Related Symptoms for Hemoglobin < 10g/dl Oncology, PC ASSIST  
Anemia: Transfusion Offered for Severe Symptomatic Anemia Oncology, PC ASSIST  
Anemia: ESP Treatment Discontinued if no Significant Hematological Response Oncology, PC ASSIST  
Fatigue/Anemia: Assessment for Presence of Anorexia or Dysphagia For Cancers Affecting the Oropharynx or Gastrointestinal Tract or Advanced Cancers Oncology, PC ASSIST  
Fatigue/Anemia: Evaluation For New Anorexia for Constipation, Nausea or Vomiting, Oral Discomfort, Depression or Dysphagia Oncology, PC ASSIST  
Fatigue/Anemia: Nutritional Counseling When Treatment Affects Nutritional Intake Oncology, PC ASSIST  
Fatigue/Anemia: Treatment of Underlying Cause of Anorexia Oncology, PC ASSIST  
Fatigue/Anemia: Assessment of Treatment for Anorexia Oncology, PC ASSIST  
Fatigue/Anemia: Assessment Prior to Treatment with Enteral or Parenteral Nutrition Oncology, PC ASSIST  
Dyspnea: Document Cause of New or Worsening Dyspnea Oncology, PC ASSIST  
Dyspnea: Symptomatic Management or Treatment Oncology, PC ASSIST  
Dyspnea: Opioids For Advanced Cancer When Non-Opiod Medications Not Effective Oncology, PC ASSIST  
Dyspnea: Thoracentesis if Malignant Pleural Effusion Oncology, PC ASSIST  
Dyspnea: Repeat Assessment of Dyspnea if Thoracentesis Oncology, PC ASSIST  
Dyspnea: Pleurodesis or Drainage Procedure if Reaccumulation and Dyspnea After Thoracentesis Oncology, PC ASSIST  
Mucositis: Oral Care Protocols Established Prior to Treatment Oncology, PC ASSIST  
Mucositis: Prophylactic Use of Palifermin For High Dose Chemotherapy or Total Body Irradiation Followed by Stem Cell Transplantation Oncology, PC ASSIST  
Mucositis: Documentation of Severity During Cytotoxic Treatments Oncology, PC ASSIST  
Mucositis: Evaluate Presence or Absence of Pain Oncology, PC ASSIST  
Mucositis: Analgesic For Pain Secondary to Treatment-Related Mucositis Oncology, PC ASSIST  
Mucositis: Nutritional Assessment Prior to Treatment Oncology, PC ASSIST  
Mucositis: Re-evaluate Mild to Moderate Mucositis Within 1 Week Oncology, PC ASSIST  
Mucositis: Re-evaluate Severe Mucositis Within 1-3 days Oncology, PC ASSIST  
Diarrhea: Assess History and Symptoms if Chemotherapy Oncology, PC ASSIST  
Diarrhea: Antidiarrheal Agent on or Before Chemotherapy if High Risk of Chemotherapy Inducement Oncology, PC ASSIST  
Diarrhea: Post-Chemotherapy Communication Plan if High Risk of Chemotherapy Inducement Oncology, PC ASSIST  
Delirium: Antipsychotic for Terminal Restlessness for Patients with Advanced Cancer Oncology, PC ASSIST  
Insomnia: Assessment for Depression or Pain Oncology, PC ASSIST  
Neutropenia: Evaluation for Patients on Chemotherapy with Fever Oncology, PC ASSIST  
Skin Rash: Education for Patients Undergoing Radiation Treatment Oncology, PC ASSIST  
Skin Rash: Treatment for Radiation-Induced Dermatitis Oncology, PC ASSIST  
Skin Rash: Evaluate if Treatment with Agents that Block Epidermal Growth Factor Oncology, PC ASSIST  
Care Planning, Advanced Cancer: Discussion of Prognosis and Advance Care Planning for Patients with Newly Discovered Advanced Cancer Oncology, PC ASSIST  
Care Planning, Advanced Cancer: Documentation of Advance Directive or Surrogate Decision Maker for Advanced Cancer Oncology, PC ASSIST  
Care Planning, Advanced Cancer: Documentation of Assessment of Pain, Spiritual Concerns, Caregiver Burdens, Financial Concerns Oncology, PC ASSIST  
Care Planning, Advanced Cancer: Referral for Palliative Care Oncology, PC ASSIST  
Care Planning, Advanced Cancer: Discussion of Prognosis and Planning for Patients with Central Nervous System Metastases Oncology, PC ASSIST  
Care Planning, Advanced Cancer: Planning Should Occur Prior to Beginning a New Chemotherapy Regimen Oncology, PC ASSIST  
Care Planning, Advanced Cancer: Document Goals of Care Before Interventions (New Hemodialysis, Pacemaker or ICD Placement, Major Surgery, Gastric Tube Placement) Oncology, PC ASSIST  
Information: Diagnosis Communicated with a Translator if the Patient Speaks a Primary Language that the Physician Does Not Speak Fluently Oncology, PC ASSIST  
Cardiovascular:      
Electrocardiogram for Syncope*+ Emergency, Cardiology, Neurology AMA/PCPI X
AMI: Electrocardiogram for Non-Traumatic Chest Pain*+ (physician) Emergency AMA/PCPI X
AMI/ACS: Aspirin at Arrival*+ (physician) Emergency AMA/PCPI, ACOVE X
AMI: Aspirin at Arrival (ED) Emergency OK QIO  
AMI/ACS: Beta Blocker at Arrival Emergency ICSI, ACOVE X
AMI: Fibrinolytic/Thrombolytic Therapy Ordered+ Emergency, Cardiology AMA/PCPI, ICSI, ACOVE  
AMI: Median Time to Fibrinolysis (ED) Emergency, Cardiology OK QIO  
AMI: Fibrinolytic Therapy Received Within 30 Minutes (ED) Emergency, Cardiology OK QIO  
AMI: Median Time to ECG (ED) Emergency, Cardiology OK QIO  
AMI: Median Time to Transfer to Another Facility (ED) Emergency, Cardiology OK QIO  
AMI: Care Coordination for PCI for AMI (communication with cardiology within 10 minutes of ECG)+ Cardiology, Emergency AMA/PCPI  
AMI: LVF Assessment (within 7 days of discharge) Cardiology ACOVE  
AMI: Depression Screening Cardiology, PC ACOVE  
MI or CABG: Cardiac Rehabilitation Cardiology ACOVE  
ACS: Non-Invasive Stress Testing (within 2 weeks of discharge) Cardiology, PC ACOVE  
ACS/Chest Pain: IV Access, Oxygen, Nitroglycerin, Morphine, Aspirin Emergency ICSI  
CAD: Antiplatelet Therapy*+ Cardiology, PC AMA/PCPI, ICSI, ACOVE X
CAD: Drug Therapy for Lowering Cholesterol*+ Cardiology, PC AMA/PCPI  
CAD: Beta Blocker Therapy-Post MI*+ Cardiology, PC NCQA, AMA/PCPI, ACOVE X
CAD: Persistent Beta Blocker Treatment After Heart Attack*+ Cardiology, PC NCQA, ACOVE  
CAD: Blood Pressure Management* Cardiology, PC NCQA, AMA/PCPI  
CAD: Percentage of Members who Have Optimally Managed Modifiable Risk Factors* Cardiology, PC Health Partners  
CAD/IVD: Lipid Profile and LDL Control* Cardiology, PC NCQA, AMA/PCPI. ICSI, ACOVE  
CAD: Drug Therapy for LDL-Cholesterol* Cardiology, PC AMA/PCPI  
CAD: Symptom and Activity Assessment* Cardiology, PC AMA/PCPI  
CAD: ACEI/ARB Therapy* Cardiology, PC AMA/PCPI, ACOVE  
CAD: Smoking Cessation Cardiology, PC AMA/PCPI, ACOVE  
CAD: Screen for Diabetes Cardiology, PC AMA/PCPI  
CAD: Estrogen/Progesterone Counseling Cardiology, PC ACOVE  
IVD: Use of Aspirin or other Antithrombotic Cardiology, PC NCQA, ACOVE  
HF: History Cardiology, PC ACOVE  
HF: ACEI/ARB Therapy*+ Cardiology, PC AMA/PCPI, ICSI, ACOVE X
HF: LVF Assessment*+ Cardiology, PC AMA/PCPI, ICSI, ACOVE  
HF: Diagnostic Testing Cardiology, PC ACOVE  
HF: Weight Measurement* Cardiology, PC AMA/PCPI  
HF: Blood Pressure Measurement Cardiology, PC AMA/PCPI  
HF: Exam-New Diagnosis (Weight, BP, Lung Exam, Cardiac, Abdominal, Lower Extremity) Cardiology, PC ACOVE  
HF: Patient Education* Cardiology, PC AMA/PCPI, ACOVE  
HF: Beta Blocker Therapy*+ Cardiology, PC AMA/PCPI, ACOVE X
HF: Warfarin Therapy for Patients with Atrial Fibrillation*+ Cardiology, PC AMA/PCPI , ICSI  
HF: Assessment of Clinical Symptoms of Volume Overload (Excess)* Cardiology, PC AMA/PCPI  
HF: Assessment of Activity Level* Cardiology, PC AMA/PCPI  
HF: Laboratory Tests Cardiology, PC AMA/PCPI  
HF: Calcium Channel Blocker Use Cardiology, PC ACOVE  
HF: Antiarrhythmic Use Cardiology, PC ACOVE  
HF: Digoxin Toxicity Cardiology, PC ACOVE  
HF: Outpatient Visit (Weight, BP, Heart Rate, Assessment of Volume Overload) Cardiology, PC ACOVE  
VTE: Patients Receiving a Baseline Platelet Count Before Starting Heparin Cardiology, Hematology, PC ICSI  
VTE: Leg Duplex Ultrasound With Depression Cardiology, Hematology, PC ICSI  
VTE: Patients Who Meet the Criteria for LMWH and for Whom LMWH is Used Cardiology, Hematology, PC ICSI  
VTE: Assessed for Graded Compression Stockings Hematology, PC ICSI  
VTE: Patients with a High Clinical Pretest Probability for PE Who Received LMWH During Evaluation Hematology, PC, Pulmonology ICSI  
VTE: Patients with DVT Treated in an Outpatient Setting Hematology, PC ICSI  
Relative Resource Use for People with Cardiovascular Conditions PC, Cardiology NCQA  
Dermatological Conditions:      
Melanoma: Patient History+ Dermatology AMA/PCPI X
Melanoma: Complete Physical Skin Exam+ Dermatology AMA/PCPI X
Melanoma: Counseling on Self-Exam+ Dermatology, PC AMA/PCPI X
Pressure Ulcers: Prevention Intervention-Pressure Reduction PC ACOVE  
Pressure Ulcers: Prevention Intervention- Nutritional Assessment PC ACOVE  
Pressure Ulcers: Assessment of Wound Characteristics PC ACOVE  
Pressure Ulcers: Pain Assessment and Treatment PC ACOVE  
Pressure Ulcers: Management-Debridement PC ACOVE  
Pressure Ulcers: Management-Wound Cleansing PC ACOVE  
Pressure Ulcers: Management-Topical Dressing PC ACOVE  
Pressure Ulcers: Management-Infection PC, Emergency ACOVE  
Pressure Ulcers: Management-Reassess Post Treatment PC, Geriatrics ACOVE  
Diabetes:      
A1C Screen*+ PC, Endocrinology NCQA, AMA/PCPI, ICSI, ACOVE  
A1C Control*+ PC, Endocrinology NCQA, AMA/PCPI, ICSI, ACOVE X
Blood Pressure Control*+ PC, Endocrinology NCQA, AMA/PCPI, ICSI, ACOVE X
Lipid Screen*+ PC, Endocrinology NCQA, AMA/PCPI, ICSI, ACOVE  
LDL Cholesterol Control*+ PC, Endocrinology NCQA, AMA/PCPI, ICSI, ACOVE X
Eye Exam*+ PC, Endocrinology, Ophthalmology NCQA, AMA/PCPI, ICSI, ACOVE  
Urine Protein Screening* PC, Endocrinology NCQA, AMA/PCPI, ICSI, ACOVE  
ACE Inhibitor or ARB for Proteinuria PC, Endocrinology ACOVE  
Foot Exam* PC, Endocrinology, Podiatry NCQA, AMA/PCPI, ICSI, ACOVE  
Smoking Status PC, Endocrinology NCQA, AMA/PCPI, ICSI  
Smoking Cessation PC, Endocrinology NCQA, AMA/PCPI, ICSI  
Aspirin Use PC, Endocrinology AMA/PCPI, ICSI, ACOVE  
Optimally Managed Modifiable Cardiovascular Risk Factors (A1C, LDL, Blood Pressure, Aspirin Use, Non-Tobacco Use) PC, Endocrinology Health Partners  
Screen for Depression PC, Endocrinology ICSI  
Relative Resource Use for People with Diabetes PC, Endocrinology NCQA  
Eye Disease/Vision:      
Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema* Ophthalmology AMA/PCPI, ACOVE X
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Patient Care*+ Ophthalmology AMA/PCPI X
Cataracts: Assessment of Visual Functional Status+ Ophthalmology AMA/PCPI, ACOVE X
Cataracts: Documentation of Pre-surgical Axial Length+ Ophthalmology AMA/PCPI X
Cataracts: Pre-surgical Dilated Fundus Evaluation+ Ophthalmology AMA/PCPI X
Cataracts: Extraction Offered Ophthalmology ACOVE  
Cataracts: Follow-up Exam After Extraction Ophthalmology ACOVE  
Cataract Surgery: Other Complications Ophthalmology Wynn et al  
Cataract Surgery: Stroke Within 30 Days Ophthalmology Wynn et al  
Cataract Surgery: Retained Nuclear Fragment Within 30 Days Ophthalmology Wynn et al  
Cataract Surgery: Myocardial Infarction Within 30 Days Ophthalmology Wynn et al  
Cataract Surgery: Nausea and Vomiting Within 30 Days Ophthalmology Wynn et al  
Cataract Surgery: Secondary Glaucoma Within 30 Days Ophthalmology Wynn et al  
Cataract Surgery: Arrythmia Within 30 Days Ophthalmology Wynn et al  
Cataract Surgery: Endophtalmitis Within 30 Days Ophthalmology Wynn et al  
Cataract Surgery: Dislocated Ocular Lens Within 30 Days Ophthalmology Wynn et al  
Cataract Surgery: Cataract Fragments in the Eye Within 30 Days Ophthalmology Wynn et al  
Cataract Surgery: Iris Prolapse Within 30 Days Ophthalmology Wynn et al  
Cataract Surgery: Hypotension Within 30 Days Ophthalmology Wynn et al  
Cataract Surgery: Retinal Detachment Within 30 Days Ophthalmology Wynn et al  
Cataract Surgery: Persistent Corneal Edema Within 30 Days Ophthalmology Wynn et al  
Cataract Surgery: Vitreous Loss Within 30 Days Ophthalmology Wynn et al  
Cataract Surgery: Persistent Iridocyclitis Ophthalmology Wynn et al  
Cataract Surgery: Respiratory Failure From Surgery Within 30 Days Ophthalmology Wynn et al  
Cataract Surgery: Hyphema Within 30 Days Ophthalmology Wynn et al  
Cataract Surgery: Persistent Cystoid Macular Edema Within 30 Days Ophthalmology Wynn et al  
Cataract Surgery: Aspiration Pneumonia Within 30 Days Ophthalmology Wynn et al  
Cataract Surgery: Ocular Hypertension Within 30 Days Ophthalmology Wynn et al  
Cataract Surgery: Retinal Break Within 30 Days Ophthalmology Wynn et al  
Cataract Surgery: Hypertension Within 30 Days Ophthalmology Wynn et al  
Glaucoma Screening in Older Adults Ophthalmology NCQA, ACOVE  
Primary Open Angle Glaucoma: Optic Nerve Evaluation*+ Ophthalmology AMA/PCPI X
Dilated Macular Examination (50+)*+ Ophthalmology AMA/PCPI, ACOVE X
Antioxidant Supplement for Age-Related Macular Degeneration+ Ophthalmology AMA/PCPI X
Vision: Urgent Signs and Symptoms PC, Ophthalmology ACOVE  
Vision: Chronic Signs and Symptoms PC, Ophthalmology ACOVE  
Vision: Corrective Lenses Ophthalmology ACOVE  
Gastro-intestinal Disorders:      
GERD: Assessment for Alarm Symptoms+ Gastroenterology, PC AMA/PCPI X
GERD: Chronic Medication Therapy+ Gastroenterology, PC AMA/PCPI  
GERD: Upper Endoscopy for Patients with Alarm Symptoms+ Gastroenterology, PC AMA/PCPI X
GERD: Biopsy for Barrett’s Esophagus+ Gastroenterology AMA/PCPI X
GERD: Barium Swallow Appropriateness+ Gastroenterology AMA/PCPI X
Hearing Loss:      
Annual Evaluation of Hearing Status PC ACOVE  
Formal Audiologic Evaluation (referral to Otolaryngologist/Audiologist) PC ACOVE  
Hearing Rehabilitation Otolaryngology ACOVE  
Conductive Hearing Loss (referral) PC ACOVE  
Cochlear Implantation Otolaryngology ACOVE  
Assistive Listening Device PC, Otolaryngology ACOVE  
Hepatitis C:      
Testing for Chronic Hepatitis C Gastroenterology, Infectious Disease, PC AMA/PCPI  
Initial HCV RNA Testing Gastroenterology, Infectious Disease, PC AMA/PCPI  
HCV Genotype Testing Prior to Therapy Gastroenterology, Infectious Disease, PC AMA/PCPI  
Consideration of Antiviral Therapy Gastroenterology, Infectious Disease, PC AMA/PCPI  
Combination Antiviral Therapy Gastroenterology, Infectious Disease, PC AMA/PCPI  
HCV RAN Testing at Week 12 of Therapy Gastroenterology, Infectious Disease, PC AMA/PCPI  
Hepatitis A and B Vaccination Gastroenterology, Infectious Disease, PC AMA/PCPI  
Counseling Regarding Use of Alcohol Gastroenterology, Infectious Disease, PC AMA/PCPI  
Counseling Regarding Use of Contraception Gastroenterology, Infectious Disease, PC AMA/PCPI  
HIV/AIDS:      
ARV Management Infectious Disease HRSA  
Adherence Self Management Infectious Disease HRSA  
Health Maintenance Infectious Disease HRSA  
Case Management Infectious Disease HRSA  
Hypertension:      
Evaluation of New Hypertension-Cardiovascular Risk PC, Cardiology ACOVE  
Renal Function Check PC, Cardiology ACOVE  
Alcohol Intake Check PC, Cardiology ACOVE  
NSAID Reduction PC, Cardiology ACOVE  
Discussion of Goal Blood Pressure PC, Cardiology ACOVE  
Improving Persistent Hypertension PC, Cardiology ACOVE  
Addressing Uncontrolled HTN PC, Cardiology ACOVE  
Immediate Care for Severe HTN PC, Cardiology ACOVE  
Orthostatic Hypotension Check PC, Cardiology ACOVE  
Beta Blocker for Hypertension and Ischemic Heart Disease PC, Cardiology ACOVE  
ACEI or ARB for Co-morbid Vascular Disease PC, Cardiology ACOVE  
Blood Pressure Measurement* PC, Cardiology AMA/PCPI  
Blood Pressure Control* PC, Cardiology CMS/NCQA, ICSI, ACOVE  
Patient Education PC, Cardiology ICSI, ACOVE  
Documented Plan of Care* PC, Cardiology AMA/PCPI, ACOVE  
Relative Resource Use for Uncomplicated Hypertension PC, Cardiology NCQA  
MRI (Head, Neck and Brain)      
Dizziness Within 30 Days Radiology Wynn et al  
Headache Within 30 Days Radiology Wynn et al  
Chest Pain Within 30 Days Radiology Wynn et al  
Seizure Within 30 Days Radiology Wynn et al  
Syncope Within 30 Days Radiology Wynn et al  
Dyspnea Within 30 Days Radiology Wynn et al  
Paresthesia Within 30 Days Radiology Wynn et al  
Bradycardia Within 30 Days Radiology Wynn et al  
Hypotension Within 30 Days Radiology Wynn et al  
Altered Mental Status Within 30 Days Radiology Wynn et al  
Rash Within 30 Days Radiology Wynn et al  
Tachycardia Within 30 Days Radiology Wynn et al  
Other Complications Within 30 Days Radiology Wynn et al  
Anaphylaxis/Anaphylactoid Reaction Within 30 Days Radiology Wynn et al  
Hypertension Within 30 Days Radiology Wynn et al  
Death Within 1 Week Radiology Wynn et al  
Medication Use (Vulnerable Elders):      
Medication Use: Clearly Defined Indication PC, All Clinical Specialties ACOVE  
Medication Use: Patient Education PC, All Clinical Specialties ACOVE  
Medication Use: Response to Therapy Documentation PC, All Clinical Specialties ACOVE  
Medication Use: Warfarin Education PC, Cardiology ACOVE  
Medication Use: Monitoring Warfarin PC, Cardiology ACOVE  
Medication Use: Lab Monitoring for ACEI PC, Cardiology ACOVE  
Medication Use: Lab Monitoring for Loop Diuretic PC ACOVE  
Medication Use: Avoid Propoxyphene PC ACOVE  
Medication Use: Taper Benzodiazepines PC, Psychiatry ACOVE  
Medication Use: Avoid Strong Anticholinergics PC ACOVE  
Medication Use: Avoid Barbituates PC ACOVE  
Medication Use: Avoid Medperidine PC ACOVE  
Medication Use: Limit Ketorolac PC ACOVE  
Medication Use: Limit Muscle Relaxants PC ACOVE  
Medication Use: Avoid Ticlopidine PC ACOVE  
Medication Use: Iron Dosing for Anemia PC ACOVE  
Medication Use: Antipsychotic Drug Response PC, Psychiatry ACOVE  
Medication Use: Acetaminophen PC ACOVE  
Medication Use: NSAIDs  – Gastrointestinal Bleeding Risks PC, Orthopedics ACOVE  
Medication Use: Daily Aspirin-Gastrointestinal Bleeding Risks PC, Cardiology ACOVE  
Medication Use: NSAIDs-Misoprostol PC, Cardiology ACOVE  
Medication Use: Aspirin-Misoprostol PC, Cardiology ACOVE  
Neurological Disorders:      
Migraine: Documented Education PC, Neurology ICSI  
Migraine: Treatment Plans PC, Neurology ICSI  
Stroke: Carotid Artery Imaging Ordered Emergency, Neurology, PC ACOVE  
Stroke: Carotid Imaging Reports: Reference to Measurement of Distal Internal Carotid Diameter*+ Radiology AMA/PCPI X
Stroke: CT or MRI Reports: Includes Documentation of the Presence or Absence of Hemorrhage and Mass Lesion and Acute Infarction*+ Radiology AMA/PCPI X
Stroke: t-PA Considered*+ Neurology, Emergency AMA/PCPI X
Stroke: Administration of Heparin (overuse) Neurology AMA/PCPI  
Stroke: Carotid Endarterectomy Neurology, Vascular Surgery ACOVE  
Stroke Risk: Anticoagulate Atrial Fibrillation Neurology, Cardiology, PC ACOVE  
Stroke Risk: Anticoagulate for Atrial Fibrillation-INR Goal Neurology, Cardiology, PC ACOVE  
Stroke Risk: Atrial Fibrillation- Antiplatelet Therapy Neurology, Cardiology, PC ACOVE  
Stroke: Ischemic Stroke Prophylaxis Neurology, PC ACOVE  
Stroke: LDL Cholesterol Neurology, PC ACOVE  
Stroke: Smoking Status Neurology, PC ACOVE  
Stroke: Smoking Cessation Neurology, PC ACOVE  
Stroke: Exercise Prescription Neurology, PC ACOVE  
Stroke: Alcohol Misuse Neurology, PC ACOVE  
Stroke: Hormone Replacement Therapy Neurology, PC ACOVE  
Stroke: Patient Education Neurology, PC ACOVE  
Sleep Disorders: Sleep History PC ACOVE  
Sleep Disorders: Sleep Hygiene Discussion PC ACOVE  
Sleep Disorders: Sleep Study Referral PC ACOVE  
Sleep Disorders: Discussion of Treatment Options PC ACOVE  
Sleep Disorders: Nocturnal Limb Movements-Referral PC ACOVE  
Sleep Disorders: Avoid Antihistamines PC ACOVE  
Sleep Disorders: Discontinue Antihistamines PC ACOVE  
Sleep Disorders: Taper Chronic Benzodiazepines PC ACOVE  
Sleep Disorders: Treat Pain Disturbing Sleep PC ACOVE  
Pneumonia:      
Chest X-Ray for CAP Emergency, PC AMA/PCPI, ICSI  
Assessment of Co-Morbid Conditions Emergency, PC AMA/PCPI  
Vital Signs for CAP* Emergency, PC AMA/PCPI X
Assessment of Oxygen Saturation for CAP* Emergency, PC AMA/PCPI X
Assessment of Mental Status for CAP* Emergency, PC AMA/PCPI X
Assessment of Hydration Status Emergency, PC AMA/PCPI  
Blood Culture Prior to Antibiotic Emergency, PC AMA/PCPI  
Empiric Antibiotic for CAP Emergency, PC AMA/PCPI X
Smoking Assessment/Intervention PC AMA/PCPI  
Influenza Immunization Status PC AMA/PCPI  
Pneumococcus Immunization Status PC AMA/PCPI  
Follow-up Care for Pneumonia PC AMA/PCPI  
Renal Disease:      
Advanced Chronic Kidney Disease (CKD): Patients on a Phosphate Binder with iPTH Measured w/in Last 3 Months Nephrology, PC Renal Physician Association (RPA)  
CKD: ACE Inhibitors or ARBs Nephrology, PC RPA  
CKD: Lipid Lowering Treatment Nephrology, PC RPA  
CKD: Elemental Calcium Nephrology RPA  
CKD: Vitamin D2 Nephrology RPA  
CKD: Calcitriol, Alfacalcidol, or Vitamin D analogues Nephrology RPA  
CKD: Referrals to Vocational Rehabilitation Center Nephrology RPA  
CKD: Screen for Dyslipidemia Within 1 Year Nephrology RPA  
CKD: Erythropoietin or Analogue Nephrology RPA  
CKD: Erythropoietin Analogue to a Hemoglobin of 12 g/dL in Women and 13 g/dL in Men Nephrology RPA  
CKD: Patients Who are Anemic, Iron Deficient and on Iron Therapy Nephrology RPA  
CKD: Patients Referred for a Transplant Evaluation Nephrology RPA  
CKD: Patients With 25 (OH) Vitamin D Levels Measured Nephrology    
CKD: Anemia Work-Up Nephrology RPA  
CKD: Patients with Antihypertensive Therapy Intensified Nephrology RPA  
CKD: Blood Pressure Checked at Every Erythropoietin or Analogue Dose Nephrology RPA  
CKD: Blood Pressure Checked at Least Once Within Last 3 Months Nephrology RPA  
CKD: Patients with Blood Pressure < 130/80mmHg and are Receiving Erythropoietin or Analogue Nephrology RPA  
CKD: Patients with Blood Pressure < 130/80 mmHg on Index Date Nephrology RPA  
CKD: Counseling for Increased Physical Activity Nephrology RPA  
CKD: Discussion of Renal Replacement Therapy Modalities Nephrology RPA  
CKD: Education Provided Nephrology RPA  
CKD: Hemoglobin Measured at Least Every 3 Months Nephrology RPA  
CKD: Patients with iPTH > 100pg/mL and/or Phosphorous > 4.5 mg/dL and are Prescribed a Low Phosphorous Diet for 1 Month Nephrology RPA  
CKD: Patients with iPTH > 100 pg/mL Nephrology RPA  
CKD: Measurement of Body Weight and Serum Albumin Within the Last 3 Months Nephrology RPA  
CKD: Patients with 1 Measurement of iPTH Nephrology RPA  
CKD: Patients with Phosphorous > than 4.5 mg.dL After a Low Phosphorous Diet for 1 Month, Now on a Phosphate Binder Nephrology RPA  
CKD: Patients with Phosphorous > 4.5 mg/dL Nephrology RPA  
CKD: Qualified Nutritional Counseling Nephrology RPA  
CKD: Patients with Serum Bicarbonate > 22 MMOL/L Nephrology RPA  
CKD: Patients with Serum Bicarbonate Measured Within the Last 3 Months Nephrology RPA  
CKD: Patients with Serum Calcium and Phosphorus Measured Within the Last 3 months Nephrology RPA  
Respiratory Illness/Asthma:      
COPD: Spirometry Results Documented* Pulmonology, PC AMA/PCPI, ACOVE X
COPD: Annual Assessment Pulmonology, PC AMA/PCPI  
COPD: Inhaled Bronchodilator* Pulmonology, PC AMA/PCPI, ACOVE X
COPD: Long-Acting Bronchodilator Pulmonology, PC AMA/PCPI, ACOVE  
COPD: Inhaler Device Training Pulmonology, PC AMA/PCPI, ACOVE  
COPD: Inhaled Corticosteroids Pulmonology, PC AMA/PCPI,  
COPD: Smoking Assessment/Cessation Pulmonology, PC AMA/PCPI,ACOVE  
COPD: Assessment of Oxygen Saturation* Pulmonology, PC AMA/PCPI, ACOVE  
COPD: Long Term Oxygen Therapy Pulmonology, PC AMA/PCPI, ACOVE  
COPD: Pulmonary Rehabilitation Pulmonology, PC AMA/PCPI  
COPD: Influenza Immunization Pulmonology, PC AMA/PCPI  
COPD: Pneumococcus Immunization Pulmonology, PC AMA/PCPI  
Asthma Assessment*+ Pulmonology, Immunology, PC AMA/PCPI X
Asthma: Appropriate Medications*+ Pulmonology, ImmunologyPC NCQA, ICSI  
Asthma: Pharmacologic Therapy*+ Pulmonology, Immunology, PC AMA/PCPI X
Asthma: Spirometry Evaluation Pulmonology, Immunology, PC ICSI  
Asthma: Bronchodilator Therapy Pulmonology, Immunology, PC AMA/PCPI  
Asthma: Patient Education Documented Pulmonology, Immunology, PC ICSI  
Asthma: Management Plan* Pulmonology, Immunology, PC IPRO (NY QIO)  
Asthma: Average Number of Lost Work Days in Past 30 Days Pulmonology, Immunology, PC HRSA  
Asthma: Average Number of Symptom Free Days in the Previous 2 weeks Pulmonology, Immunology, PC HRSA  
Asthma: Influenza Immunization Pulmonology, Immunology, PC HRSA  
Asthma: Patients Who Have Had a Visit to the ED in the Past Year Pulmonology, Immunology, PC HRSA  
Asthma: Depression Screening Pulmonology, Immunology, PC HRSA  
Asthma: Patients with Reported Exposure to Environmental Tobacco Smoke at Last Visit Pulmonology, Immunology, PC HRSA  
Asthma: Patients with a Severity Assessment at the Last Visit Pulmonology, Immunology, PC HRSA  
Asthma: Patients with Documented Self Management Goals Pulmonology, Immunology, PC HRSA  
Asthma: Anti-inflammatory Medication Pulmonology, Immunology, PC HRSA  
Relative Resource Use for People with Asthma Pulmonology, Immunology, PC NCQA  
Relative Resource Use for People with COPD Pulmonology, Immunology, PC NCQA  
Acute Bronchitis: Inappropriate Antibiotic Treatment* PC, Emergency NCQA  
Viral Upper Respiratory Infection: Patient Education PC, Emergency ICSI  
Viral Upper Respiratory Infection: Appropriate Antibiotic Use PC, Emergency ICSI  
Viral Upper Respiratory Infection: Inappropriate Office Visit PC, Emergency ICSI  
Pharyngitis: Appropriate Testing PC, Emergency ICSI X
Undernutrition:      
Weight Measurement PC ACOVE  
Vitamin D PC ACOVE  
Document Weight Loss PC ACOVE  
Evaluate Weight Loss PC ACOVE  
Evaluate Co-Morbid Conditions PC ACOVE  
Urological Conditions:      
Discussing Urinary Incontinence* PC NCQA, ACOVE  
Receiving Urinary Incontinence Treatment* PC, Urology NCQA, ACOVE  
Assessment of Presence of Urinary Incontinence (Women 65+)*+ PC, OB/GYN, Urology AMA/PCPI, ACOVE X
Incontinence: History PC, Urology ACOVE  
Incontinence: Urine Evaluation PC, Urology ACOVE  
Incontinence: Post-Void Residual PC, Urology ACOVE  
Incontinence: Behavioral Therapy Assessment PC, Urology AMA/PCPI, ACOVE  
Incontinence: Characterization of UI (Women 65+)*+ PC, OB/GYN, Urology AMA/PCPI, ACOVE X
Incontinence: Plan of Care for UI (Women 65+)*+ PC, OB/GYN,Urology AMA/PCPI, ACOVE X
Incontinence: Assess Response to Treatment PC, OB/GYN, Urology ACOVE  
Incontinence: Preoperative Urodynamic Testing Urology, OB/GYN ACOVE  
Incontinence: Chronic Urethral Catheter Urology ACOVE  
UTI: Urine Culture Performed PC ICSI, ACOVE  
UTI: Recommended Short Course Therapy PC ACOVE  
BPH: History PC, Urology ACOVE  
BPH: Exam PC, Urology ACOVE  
BPH: Urine Evaluation PC, Urology ACOVE  
BPH: Post-Void Residual PC, Urology ACOVE  
BPH: Urologic Trauma (referral to urologist) PC ACOVE  
BPH: Hematuria-Urinalysis PC ACOVE  
BPH: Hematuria-Testing and Referral PC, Geriatrics, Urology ACOVE  
BPH: PSA Testing PC, Geriatrics, Urology ACOVE  
BPH: Referral Indications PC, Geriatrics ACOVE  
BPH: Treatment-If AUA SI Score < 7 and Symptoms not Bothersome, No Medication or Surgery PC, Geriatrics, Urology ACOVE  
BPH: Treatment- If AUA SI score > 7, With Moderate to Severe Symptoms, Discuss Treatment Options PC, Geriatrics, Urology ACOVE  
BPH: Preoperative Urine Evaluation PC, Geriatrics, Urology ACOVE  
Other Clinical:      
Radiology: Timeliness of Verifying Reports Radiology Veteran’s Health Admin  
ED Patients who Left Against Medical Advice or Without Being Seen Emergency CMS  
Patient Received Discharge Instructions on Discharge from the ED Emergency CMS  
Pain Management: Education for Persistent Pain PC ACOVE  
Pain Management: Preventing Constipation with Opioids PC ACOVE, ASSIST  
Reassessing Pain Control with Opioids PC ACOVE, ASSIST  
End of Life Care: Comprehensive Assessment PC, Palliative, All Clinical Specialties ACOVE  
End of Life Care: Goals of Care Surrogate Discussion PC, Palliative, All Clinical Specialties ACOVE  
End of Life Care: Advance Directive Continuity PC, Palliative, All Clinical Specialties ACOVE, ASSIST  
End of Life Care: Follow Treatment Preferences PC, Palliative, All Clinical Specialties ACOVE  
End of Life Care: Gastrostomy  – Tube Placement PC, Palliative, All Clinical Specialties ACOVE  
End of Life Care: Dyspnea Assessment PC, All Clinical Specialties ACOVE  
End of Life Care: Treatment of Dyspnea PC, All Clinical Specialties ACOVE  
End of Life Care: Plan for Management of Emergent Dyspnea PC, All Clinical Specialties ACOVE  
End of Life Care: Document Dyspnea Care PC, All Clinical Specialties ACOVE  
End of Life Care: Plan for Management of Emergent Pain PC, All Clinical Specialties ACOVE  
End of Life Care: Document Presence or Absence of Pain PC, All Clinical Specialties ACOVE  
End of Life Care: Plan for Management of Emergent Obstruction PC, All Clinical Specialties ACOVE  
End of Life Care: Caregiver Stress Assessed PC, All Clinical Specialties ACOVE  
End of Life Care: Spouse/Significant Other Assessed for Depression or Suicidality PC, All Clinical Specialties ACOVE  
Continuity and Coordination of Care: Identify Source of Care PC, All Clinical Specialties ACOVE  
Continuity and Coordination of Care: Medication Continuity-Follow-up Visit PC, All Clinical Specialties ACOVE  
Continuity and Coordination of Care: Medication Continuity-> 2 Physicians PC, All Clinical Specialties ACOVE  
Continuity and Coordination of Care: Consultation Continuity PC, All Clinical Specialties ACOVE  
Continuity and Coordination of Care: Test Continuity PC, All Clinical Specialties ACOVE  
Continuity and Coordination of Care: Prevention Reminders PC ACOVE  
Continuity and Coordination of Care: Communication with PCP Following ED Visit Emergency ACOVE  
Continuity and Coordination of Care: Post-Hospitalization Medications PC, All Clinical Specialties ACOVE  
Continuity and Coordination of Care: Post-Hospitalization Tests PC, All Clinical Specialties ACOVE  
Continuity and Coordination of Care: Post-Hospitalization Appointments PC, All Clinical Specialties ACOVE  
Continuity and Coordination of Care: Outside Medical Records PC ACOVE  
Continuity and Coordination of Care: Interpreter PC, All Specialties ACOVE  
Fall Risk Management* PC NCQA, ACOVE X
Falls and Mobility Problems: Fall History PC ACOVE  
Falls and Mobility Problems: Fall Exam-Orthostatic Vital Signs PC ACOVE  
Falls and Mobility Problems: Fall-Exam-Eye Exam PC ACOVE  
Falls and Mobility Problems: Gait, Balance and Strength Evaluation PC, Orthopedics ACOVE  
Falls and Mobility Problems: Cognitive Evaluation PC ACOVE  
Falls and Mobility Problems: Home Hazard Evaluation PC ACOVE  
Falls and Mobility Problems: Benzodiazepine Discontinuation PC ACOVE  
Falls and Mobility Problems: Assistive Device for Balance Disorder PC ACOVE  
Falls and Mobility Problems: Assistive Device Review PC ACOVE  
Falls and Mobility Problems: Exercise Program PC ACOVE  
Patient Experience:      
Hospital CAHPS (selected questions) PC, All Specialties AHRQ  
Clinical-Group Ambulatory CAHPS PC, All Specialties AHRQ  

PC Indicates Primary Care, including Geriatrics.
ACOVE (Assessing Care of Vulnerable Elders) measures are applicable to community-dwelling individuals age 65 and older at increased risk of functional decline and death over a two-year period.
This table includes measures that are publicly available.  RAND’s review did not include proprietary measures.

View full report

Preview
Download

"outpatient.pdf" (pdf, 1001.94Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®