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Merge pull request #733 from CMSgov/feat/QPPA-8297
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QPPA-8297: IA measure update  for PY24
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@ckawell-sb
ckawell-sb authored Nov 17, 2023
2 parents adfd894 + 36a796f commit 04f596a
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75 changes: 75 additions & 0 deletions measures/2024/measures-data.json
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Expand Up @@ -1673,6 +1673,81 @@
"M0005"
]
},
{
"category": "ia",
"title": "Improving Practice Capacity for Human Immunodeficiency Virus (HIV) Prevention Services",
"description": "Establish policies and procedures to improve practice capacity to increase HIV prevention screening, improve HIV prevention education and awareness, and reduce disparities in pre-exposure prophylaxis (PrEP) uptake. Use one or more of the following activities:\n• Implement electronic health record (EHR) prompts or clinical decision support tools to increase appropriate HIV prevention screening; \n• Require that providers and designated clinical staff take part in at least one educational opportunity that includes components on the importance and application of HIV prevention screening and PrEP initiation in clinical practice; and/or \n• Assess and refine current policies for HIV prevention screening, including integrated sexually transmitted infection (STI)/HIV testing processes, universal HIV screening, and PrEP initiation.",
"measureId": "IA_PM_22",
"metricType": "boolean",
"firstPerformanceYear": 2024,
"lastPerformanceYear": null,
"weight": "medium",
"subcategoryId": "populationManagement",
"allowedPrograms": [
"mips",
"app1"
]
},
{
"category": "ia",
"title": "Practice-Wide Quality Improvement in MIPS Value Pathways",
"description": "Create a quality improvement initiative within your practice and create a culture in which all staff actively participates. Clinicians must be participating in MIPS Value Pathways (MVPs) to attest to this activity.\n\nCreate a quality improvement plan that involves a minimum of three of the measures within a specific MVP and that is characterized by the following:\n• Train all staff in quality improvement methods, particularly as related to other quality initiatives currently underway in the practice;\n• Promote transparency and accelerate improvement by sharing practice-level and panel-level quality of care and patient experience and utilization data with staff;\n• Integrate practice change/quality improvement into all staff duties, including communication and education regarding all current quality initiatives;\n• Designate regular team meetings to review data and plan improvement cycles with defined, iterative goals as appropriate; and/or\n• Promote transparency and engage patients and families by sharing practice-level quality of care and patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data.\n\nIn addition, clinicians may consider:\n• Creation of specific plans for recognition of individual or groups of clinicians and staff when they meet certain practice-defined quality goals. Examples include recognition for achieving success in measure reporting and/or a high level of effort directed to quality improvement and practice standardization; or\n• Participation in the American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.",
"measureId": "IA_MVP",
"metricType": "boolean",
"firstPerformanceYear": 2024,
"lastPerformanceYear": null,
"weight": "high",
"subcategoryId": null,
"allowedPrograms": [
"mips",
"app1"
]
},
{
"category": "ia",
"title": "Use of Computable Guidelines and Clinical Decision Support to Improve Adherence for Cervical Cancer Screening and Management Guidelines",
"description": "Incorporate the Cervical Cancer Screening and Management (CCSM) Clinical Decision Support (CDS) tool within the electronic health record (EHR) system to provide clinicians with ready access to and assisted interpretation of the most up-to-date clinical practice guidelines in CCSM to ensure adequate screening, timely follow-up, and optimal patient care.\n\nThe CCSM CDS helps ensure that patient populations receive adequate screening and management, according to evidence-based recommendations in the United States Preventive Services Task Force (USPSTF) screening and American Society for Colposcopy and Cervical Pathology (ASCCP) management guidelines for cervical cancer. The CDS integrates into the clinical workflow a clinician-facing dashboard to support the clinician’s awareness and adoption of and preventive care for cervical cancer, including screening and any necessary follow-up treatment.\n\nThe CCSM CDS is fully conformant with the HL7 Fast Healthcare Interoperability Resources (FHIR) standard, so it can be used with any certified EHR platform. The CDS Hooks and SMART-on-FHIR interoperability interface standards provide two ways to integrate with the clinical workflow in a way that complements existing displays and information pre-visit, during visit, and for post-visit follow-up. CCSM CDS helps the clinician evaluate the patient’s clinical data against existing guidance and displays patient-specific recommendations.",
"measureId": "IA_PM_23",
"metricType": "boolean",
"firstPerformanceYear": 2024,
"lastPerformanceYear": null,
"weight": "high",
"subcategoryId": "populationManagement",
"allowedPrograms": [
"mips",
"app1"
]
},
{
"category": "ia",
"title": "Behavioral/Mental Health and Substance Use Screening & Referral for Pregnant and Postpartum Women",
"description": "Screen for perinatal mood and anxiety disorders (PMADs) and substance use disorder (SUD) in pregnant and postpartum women, and screen and refer to treatment and/or refer to appropriate social services, and document this in patient care plans.",
"measureId": "IA_BMH_14",
"metricType": "boolean",
"firstPerformanceYear": 2024,
"lastPerformanceYear": null,
"weight": "high",
"subcategoryId": "behavioralAndMentalHealth",
"allowedPrograms": [
"mips",
"app1"
]
},
{
"category": "ia",
"title": "Behavioral/Mental Health and Substance Use Screening & Referral for Older Adults",
"description": "Complete age-appropriate screening for mental health and substance use in older adults, as well as screening and referral to treatment and/or referral to appropriate social services, and document this in-patient care plans.",
"measureId": "IA_BMH_15",
"metricType": "boolean",
"firstPerformanceYear": 2024,
"lastPerformanceYear": null,
"weight": "high",
"subcategoryId": "behavioralAndMentalHealth",
"allowedPrograms": [
"mips",
"app1"
]
},
{
"category": "pi",
"measureId": "PI_PPHI_1",
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144 changes: 72 additions & 72 deletions scripts/constants.ts
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Expand Up @@ -120,19 +120,19 @@ export const COLLECTION_TYPES_FIELDS = [
];

export const COLLECTION_TYPES = {
'PartBClaims': 'claims',
'CSV': 'certifiedSurveyVendor',
'eCQM': 'electronicHealthRecord',
'CMSWI': 'cmsWebInterface',
'AdminClaims': 'administrativeClaims',
'MIPSCQM': 'registry',
'QCDR': 'registry',
'partbclaims': 'claims',
'csv': 'certifiedSurveyVendor',
'ecqm': 'electronicHealthRecord',
'cmswi': 'cmsWebInterface',
'adminclaims': 'administrativeClaims',
'mipscqm': 'registry',
'qcdr': 'registry',
};

export const MEASURE_TYPES = {
'process': 'process',
'outcome': 'outcome',
'patientEngagement/experience': 'patientEngagementExperience',
'patientengagement/experience': 'patientEngagementExperience',
'efficiency': 'efficiency',
'intermediateoutcome': 'intermediateOutcome',
'structure': 'structure',
Expand All @@ -141,89 +141,89 @@ export const MEASURE_TYPES = {
};

export const OBJECTIVES = {
'ProtectPatientHealthInformation': 'protectPatientHealthInformation',
'PublicHealthAndClinicalDataExchange': 'publicHealthAndClinicalDataExchange',
'ProvidertoPatientExchange': 'providerToPatientExchange',
'e-Prescribing': 'electronicPrescribing',
'HealthInformationExchange': 'healthInformationExchange',
'protectpatienthealthinformation': 'protectPatientHealthInformation',
'publichealthandclinicaldataexchange': 'publicHealthAndClinicalDataExchange',
'providertopatientexchange': 'providerToPatientExchange',
'e-prescribing': 'electronicPrescribing',
'healthinformationexchange': 'healthInformationExchange',
'attestation': 'attestation',
'NULL': null,
'null': null,
};

export const REPORTING_CATEGORY = {
'required': 'required',
'bonus': 'bonus',
'exclusion': 'exclusion',
'NULL': null,
'null': null,

};

export const WEIGHT = {
'high': 'high',
'medium': 'medium',
'NULL': null,
'null': null,
};

export const SUBCATEGORY_NAME = {
'AchievingHealthEquity': 'achievingHealthEquity',
'BehavioralAndMentalHealth': 'behavioralAndMentalHealth',
'BeneficiaryEngagement': 'beneficiaryEngagement',
'CareCoordination': 'careCoordination',
'EmergencyResponseAndPreparedness': 'emergencyResponseAndPreparedness',
'ExpandedPracticeAccess': 'expandedPracticeAccess',
'PatientSafetyAndPracticeAssessment': 'patientSafetyAndPracticeAssessment',
'PopulationManagement': 'populationManagement',
'NULL': null,
'achievinghealthequity': 'achievingHealthEquity',
'behavioralandmentalhealth': 'behavioralAndMentalHealth',
'beneficiaryengagement': 'beneficiaryEngagement',
'carecoordination': 'careCoordination',
'emergencyresponseandpreparedness': 'emergencyResponseAndPreparedness',
'expandedpracticeaccess': 'expandedPracticeAccess',
'patientsafetyandpracticeassessment': 'patientSafetyAndPracticeAssessment',
'populationmanagement': 'populationManagement',
'null': null,
};

export const MEASURE_SETS = {
'Allergy/Immunology': 'allergyImmunology',
'Anesthesiology': 'anesthesiology',
'Cardiology': 'cardiology',
'Electro-physiologyCardiacSpecialist': 'electrophysiologyCardiacSpecialist',
'Gastro-enterology': 'gastroenterology',
'Dermatology': 'dermatology',
'EmergencyMedicine': 'emergencyMedicine',
'FamilyMedicine': 'familyMedicine',
'InternalMedicine': 'internalMedicine',
'Obstetrics/Gynecology': 'obstetricsGynecology',
'Ophthalmology/Optometry': 'ophthalmology',
'OrthopedicSurgery': 'orthopedicSurgery',
'Otolaryngology': 'otolaryngology',
'Pathology': 'pathology',
'Pediatrics': 'pediatrics',
'PhysicalMedicine': 'physicalMedicine',
'PlasticSurgery': 'plasticSurgery',
'PreventiveMedicine': 'preventiveMedicine',
'Neurology': 'neurology',
'Mental/BehavioralHealthandPsychiatry': 'mentalBehavioralHealth',
'DiagnosticRadiology': 'diagnosticRadiology',
'InterventionalRadiology': 'interventionalRadiology',
'VascularSurgery': 'vascularSurgery',
'GeneralSurgery': 'generalSurgery',
'ThoracicSurgery': 'thoracicSurgery',
'Urology': 'urology',
'Oncology/Hematology': 'oncology',
'RadiationOncology': 'radiationOncology',
'Hospitalists': 'hospitalists',
'Rheumatology': 'rheumatology',
'Nephrology': 'nephrology',
'InfectiousDisease': 'infectiousDisease',
'Neurosurgical': 'neurosurgical',
'Podiatry': 'podiatry',
'PhysicalTherapy/OccupationalTherapy': 'physicalTherapyOccupationalTherapy',
'Geriatrics': 'geriatrics',
'UrgentCare': 'urgentCare',
'SkilledNursingFacility': 'skilledNursingFacility',
'Dentistry': 'dentistry',
'ClinicalSocialWork': 'clinicalSocialWork',
'Audiology': 'audiology',
'CertifiedNurseMidwife': 'certifiedNurseMidwife',
'ChiropracticMedicine': 'chiropracticMedicine',
'Endocrinology': 'endocrinology',
'Nutrition/Dietician': 'nutritionDietician',
'Pulmonology': 'pulmonology',
'SpeechLanguagePathology': 'speechLanguagePathology',
'allergy/immunology': 'allergyImmunology',
'anesthesiology': 'anesthesiology',
'cardiology': 'cardiology',
'electro-physiologycardiacspecialist': 'electrophysiologyCardiacSpecialist',
'gastro-enterology': 'gastroenterology',
'dermatology': 'dermatology',
'emergencmedicine': 'emergencyMedicine',
'familymedicine': 'familyMedicine',
'internalmedicine': 'internalMedicine',
'obstetrics/gynecology': 'obstetricsGynecology',
'ophthalmology/optometry': 'ophthalmology',
'orthopedicsurgery': 'orthopedicSurgery',
'otolaryngology': 'otolaryngology',
'pathology': 'pathology',
'pediatrics': 'pediatrics',
'physicalmedicine': 'physicalMedicine',
'plasticsurgery': 'plasticSurgery',
'preventivemedicine': 'preventiveMedicine',
'neurology': 'neurology',
'mental/behavioralhealthandpsychiatry': 'mentalBehavioralHealth',
'diagnosticradiology': 'diagnosticRadiology',
'interventionalradiology': 'interventionalRadiology',
'vascularsurgery': 'vascularSurgery',
'generalsurgery': 'generalSurgery',
'thoracicsurgery': 'thoracicSurgery',
'urology': 'urology',
'oncology/hematology': 'oncology',
'radiationoncology': 'radiationOncology',
'hospitalists': 'hospitalists',
'rheumatology': 'rheumatology',
'nephrology': 'nephrology',
'infectiousdisease': 'infectiousDisease',
'neurosurgical': 'neurosurgical',
'podiatry': 'podiatry',
'physicaltherapy/occupationaltherapy': 'physicalTherapyOccupationalTherapy',
'geriatrics': 'geriatrics',
'urgentcare': 'urgentCare',
'dkillednursingfacility': 'skilledNursingFacility',
'fentistry': 'dentistry',
'vlinicalsocialwork': 'clinicalSocialWork',
'audiology': 'audiology',
'certifiednursemidwife': 'certifiedNurseMidwife',
'chiropracticmedicine': 'chiropracticMedicine',
'endocrinology': 'endocrinology',
'nutrition/dietician': 'nutritionDietician',
'pulmonology': 'pulmonology',
'speechlanguagepathology': 'speechLanguagePathology',
};

export const QUALITY_MEASURES_ORDER = {
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4 changes: 2 additions & 2 deletions scripts/measures/lib/csv-json-converter.ts
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Expand Up @@ -161,8 +161,8 @@ function mapArrayItem(field: string, map: any, values: string) {

function mapItem(field: string, map: any, value: string) {
// .replace(/\s/g, "") removes all whitespace.
if (typeof map[value.replace(/\s/g, "")] !== 'undefined') {
return map[value.replace(/\s/g, "")];
if (typeof map[value.replace(/\s/g, "").toLowerCase()] !== 'undefined') {
return map[value.replace(/\s/g, "").toLowerCase()];
}
else {
throw new InvalidValueError(field, value);
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25 changes: 25 additions & 0 deletions updates/measures/2024/IA_PY24_CR_20231114.csv
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Category,Measure ID,Measure Title,Measure Description,First Performance Year,Year Removed,Weight,Subcategory Name
Value: IA,,,,,Enter current PY if measure is to be removed,"Values: high, medium, NULL","Values: Achieving Health Equity, Behavioral And Mental Health, Beneficiary Engagement, Care Coordination, Emergency Response And Preparedness, Expanded Practice Access, Patient Safety And Practice Assessment, Population Management, NULL"
IA,IA_PM_22,Improving Practice Capacity for Human Immunodeficiency Virus (HIV) Prevention Services,"Establish policies and procedures to improve practice capacity to increase HIV prevention screening, improve HIV prevention education and awareness, and reduce disparities in pre-exposure prophylaxis (PrEP) uptake. Use one or more of the following activities:
• Implement electronic health record (EHR) prompts or clinical decision support tools to increase appropriate HIV prevention screening;
• Require that providers and designated clinical staff take part in at least one educational opportunity that includes components on the importance and application of HIV prevention screening and PrEP initiation in clinical practice; and/or
• Assess and refine current policies for HIV prevention screening, including integrated sexually transmitted infection (STI)/HIV testing processes, universal HIV screening, and PrEP initiation.",2024,,Medium,Population Management
IA,IA_MVP,Practice-Wide Quality Improvement in MIPS Value Pathways ,"Create a quality improvement initiative within your practice and create a culture in which all staff actively participates. Clinicians must be participating in MIPS Value Pathways (MVPs) to attest to this activity.

Create a quality improvement plan that involves a minimum of three of the measures within a specific MVP and that is characterized by the following:
• Train all staff in quality improvement methods, particularly as related to other quality initiatives currently underway in the practice;
• Promote transparency and accelerate improvement by sharing practice-level and panel-level quality of care and patient experience and utilization data with staff;
• Integrate practice change/quality improvement into all staff duties, including communication and education regarding all current quality initiatives;
• Designate regular team meetings to review data and plan improvement cycles with defined, iterative goals as appropriate; and/or
• Promote transparency and engage patients and families by sharing practice-level quality of care and patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data.

In addition, clinicians may consider:
• Creation of specific plans for recognition of individual or groups of clinicians and staff when they meet certain practice-defined quality goals. Examples include recognition for achieving success in measure reporting and/or a high level of effort directed to quality improvement and practice standardization; or
• Participation in the American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.",2024,,High,NULL
IA,IA_PM_23,Use of Computable Guidelines and Clinical Decision Support to Improve Adherence for Cervical Cancer Screening and Management Guidelines,"Incorporate the Cervical Cancer Screening and Management (CCSM) Clinical Decision Support (CDS) tool within the electronic health record (EHR) system to provide clinicians with ready access to and assisted interpretation of the most up-to-date clinical practice guidelines in CCSM to ensure adequate screening, timely follow-up, and optimal patient care.

The CCSM CDS helps ensure that patient populations receive adequate screening and management, according to evidence-based recommendations in the United States Preventive Services Task Force (USPSTF) screening and American Society for Colposcopy and Cervical Pathology (ASCCP) management guidelines for cervical cancer. The CDS integrates into the clinical workflow a clinician-facing dashboard to support the clinician’s awareness and adoption of and preventive care for cervical cancer, including screening and any necessary follow-up treatment.

The CCSM CDS is fully conformant with the HL7 Fast Healthcare Interoperability Resources (FHIR) standard, so it can be used with any certified EHR platform. The CDS Hooks and SMART-on-FHIR interoperability interface standards provide two ways to integrate with the clinical workflow in a way that complements existing displays and information pre-visit, during visit, and for post-visit follow-up. CCSM CDS helps the clinician evaluate the patient’s clinical data against existing guidance and displays patient-specific recommendations.",2024,,High,Population Management
IA,IA_BMH_14,Behavioral/Mental Health and Substance Use Screening & Referral for Pregnant and Postpartum Women,"Screen for perinatal mood and anxiety disorders (PMADs) and substance use disorder (SUD) in pregnant and postpartum women, and screen and refer to treatment and/or refer to appropriate social services, and document this in patient care plans.",2024,,High,Behavioral and Mental Health
IA,IA_BMH_15,Behavioral/Mental Health and Substance Use Screening & Referral for Older Adults,"Complete age-appropriate screening for mental health and substance use in older adults, as well as screening and referral to treatment and/or referral to appropriate social services, and document this in-patient care plans.",2024,,High,Behavioral and Mental Health
3 changes: 2 additions & 1 deletion updates/measures/2024/changes.meta.json
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@@ -1,4 +1,5 @@
[
"IA_PY24_CR_20230809.csv",
"PI_PY24_CR_20230721.csv"
"PI_PY24_CR_20230721.csv",
"IA_PY24_CR_20231114.csv"
]

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