2555 lines
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2555 lines
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<a href="/about-quality/quality-at-CMS/principles">
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<span>Measure Development Principles</span>
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</ul>
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</div>
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<span><strong>Blueprint Measure Lifecycle</strong></span>
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<ul id="basic-nav-section-Blueprint-Measure-Lifecycle" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Blueprint-Measure-Lifecycle" >
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<span>Blueprint Measure Lifecycle Overview</span>
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<a href="/about-quality/blueprint-measure-lifecycle/theory">
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<span>Measure Development Theory</span>
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</a>
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</ul>
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<span><strong>Measure Conceptualization</strong></span>
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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
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<a href="/measure-lifecycle/measure-conceptualization/overview">
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<span>Overview</span>
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</a>
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</li>
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<li class="usa-nav__submenu-item menu_level_2 is_expanded">
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<span>Information Gathering</span>
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<span>Overview</span>
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</li>
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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
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<a href="/measure-lifecycle/measure-conceptualization/information-gathering/conduct-environment-scan">
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<span>Conduct an Environmental Scan</span>
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</a>
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</li>
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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
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<a href="/measure-lifecycle/measure-conceptualization/information-gathering/analyze-data-gap-analysis">
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<span>Analyze Data & Conduct Gap Analysis</span>
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</a>
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</li>
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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
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<a href="/measure-lifecycle/measure-conceptualization/information-gathering/respecified-measures">
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<span>Respecified Measures</span>
|
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</a>
|
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|
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</li>
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|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-conceptualization/information-gathering/justify-creation-new-measures">
|
||
<span>Justify the Creation of New Measures</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_expanded">
|
||
|
||
|
||
|
||
<button id="usa-accordion__button_second-2 usa-nav__submenu-list-2" class="usa-accordion__button_second usa-nav__link is_expanded closed" aria-expanded="false" aria-controls="basic-nav-section-Measure-Conceptualization">
|
||
<span>Business Case Development</span>
|
||
</button>
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Business-Case-Development" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Business-Case-Development" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-conceptualization/business-case/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-conceptualization/business-case/outcomes">
|
||
<span>Documenting Outcomes, Benefits, & Costs</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-conceptualization/business-case/best-practices">
|
||
<span>Business Case Best Practices</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</div>
|
||
|
||
|
||
<div class="desktop:grid-col-3">
|
||
|
||
<div class="usa-nav__headermenu-item">
|
||
<span><strong>Measure Specification</strong></span>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Measure-Specification" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Measure-Specification" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/specifications-measure-category">
|
||
<span>Specifications by Measure Category</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/define-data-sources">
|
||
<span>Define Data Sources</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_expanded">
|
||
|
||
|
||
|
||
<button id="usa-accordion__button_second-3 usa-nav__submenu-list-2" class="usa-accordion__button_second usa-nav__link usa-currentis_expanded closed" aria-expanded="false" aria-controls="basic-nav-section-Measure-Specification">
|
||
<span>Develop Specifications</span>
|
||
</button>
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Develop-Specifications" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Develop-Specifications" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/develop-specification/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/develop-specification/target-initial-population">
|
||
<span>Define the Target/Initial Population</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/develop-specification/denominator">
|
||
<span>Define the Denominator</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/develop-specification/numerator">
|
||
<span>Define the Numerator and Exclusions</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/develop-specification/stratification">
|
||
<span>Define Stratification Scheme</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/develop-specification/respecifying-registry-measures">
|
||
<span>Respecifying Registry Measures to Electronic Clinical Quality Measures (eCQMs)</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_expanded">
|
||
|
||
|
||
|
||
<button id="usa-accordion__button_second-3 usa-nav__submenu-list-2" class="usa-accordion__button_second usa-nav__link is_expanded closed" aria-expanded="false" aria-controls="basic-nav-section-Measure-Specification">
|
||
<span>Specify the Code</span>
|
||
</button>
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Specify-the-Code" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Specify-the-Code" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/specify-code/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/specify-code/code-systems-vocabularies-terminologies">
|
||
<span>Code Systems, Vocabularies, and Terminologies</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/specify-code/encode-clinical-information">
|
||
<span>Encoding Clinical Information</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/specify-code/data-standards">
|
||
<span>Data Standards</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_expanded">
|
||
|
||
|
||
|
||
<button id="usa-accordion__button_second-3 usa-nav__submenu-list-2" class="usa-accordion__button_second usa-nav__link is_expanded closed" aria-expanded="false" aria-controls="basic-nav-section-Measure-Specification">
|
||
<span>Construct Data Protocol</span>
|
||
</button>
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Construct-Data-Protocol" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Construct-Data-Protocol" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/data-protocol/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/data-protocol/key-terms">
|
||
<span>Define Key Terms, Data Elements, Codes, and Code Systems</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/data-protocol/level-measurement-analysis">
|
||
<span>Describe Level of Measurement & Sampling</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/data-protocol/risk-adjustment">
|
||
<span>Determine Risk Adjustment</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/data-protocol/time-interval">
|
||
<span>Define Any Time Intervals</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/data-protocol/scoring">
|
||
<span>Describe Scoring & Calculation Algorithm</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/document-measure">
|
||
<span>Document the Measures</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_expanded">
|
||
|
||
|
||
|
||
<button id="usa-accordion__button_second-3 usa-nav__submenu-list-2" class="usa-accordion__button_second usa-nav__link is_expanded closed" aria-expanded="false" aria-controls="basic-nav-section-Measure-Specification">
|
||
<span>Measure Harmonization</span>
|
||
</button>
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Measure-Harmonization" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Measure-Harmonization" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/measure-harmonization/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/measure-harmonization/alignment">
|
||
<span>Measure Harmonization and Alignment</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/measure-harmonization/when-to-consider">
|
||
<span>When to Consider Measure Harmonization</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</div>
|
||
|
||
|
||
<div class="desktop:grid-col-3">
|
||
|
||
<div class="usa-nav__headermenu-item">
|
||
<span><strong>Measure Testing</strong></span>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Measure-Testing" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Measure-Testing" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-testing/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_expanded">
|
||
|
||
|
||
|
||
<button id="usa-accordion__button_second-4 usa-nav__submenu-list-2" class="usa-accordion__button_second usa-nav__link is_expanded closed" aria-expanded="false" aria-controls="basic-nav-section-Measure-Testing">
|
||
<span>Measure Testing Process</span>
|
||
</button>
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Measure-Testing-Process" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Measure-Testing-Process" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-testing/process/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-testing/process/develop-workplan">
|
||
<span>Develop The Testing Work Plan</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-testing/process/perform-sampl">
|
||
<span>Perform Sampling</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-testing/process/implement-and-analyze">
|
||
<span>Implement, Analyze, Refine & Retest</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-testing/process/summary">
|
||
<span>Measure Testing Summary</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-testing/process/testing-respecified-measures">
|
||
<span>Testing Respecified Measures</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_expanded">
|
||
|
||
|
||
|
||
<button id="usa-accordion__button_second-4 usa-nav__submenu-list-2" class="usa-accordion__button_second usa-nav__link is_expanded closed" aria-expanded="false" aria-controls="basic-nav-section-Measure-Testing">
|
||
<span>Measure Evaluation Criteria</span>
|
||
</button>
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Measure-Evaluation-Criteria" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Measure-Evaluation-Criteria" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-testing/evaluation-criteria/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-testing/evaluation-criteria/importance">
|
||
<span>Importance</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-testing/evaluation-criteria/scientific-acceptability">
|
||
<span>Scientific Acceptability</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-testing/evaluation-criteria/feasibility">
|
||
<span>Feasibility</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-testing/evaluation-criteria/usability">
|
||
<span>Usability & Use</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</div>
|
||
|
||
|
||
<div class="desktop:grid-col-3">
|
||
|
||
<div class="usa-nav__headermenu-item">
|
||
<span><strong>Measure Implementation</strong></span>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Measure-Implementation" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Measure-Implementation" >
|
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|
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|
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|
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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-implementation/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-implementation/selection">
|
||
<span>Measure Selection</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
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|
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<li class="usa-nav__submenu-item menu_level_2 is_expanded">
|
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<span>Pre-Rulemaking</span>
|
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</button>
|
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|
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<ul id="basic-nav-section-Pre-Rulemaking" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Pre-Rulemaking" >
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|
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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
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|
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<a href="/measure-lifecycle/measure-implementation/pre-rulemaking/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-implementation/pre-rulemaking/guidance-measure-submitters">
|
||
<span>Guidance for Measure Submitters</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-implementation/pre-rulemaking/measure-priorities">
|
||
<span>Measure Priorities</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-implementation/pre-rulemaking/lists-and-reports">
|
||
<span>MUC Lists and Recommendation Reports</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-implementation/rollout">
|
||
<span>Measure Rollout</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_expanded">
|
||
|
||
|
||
|
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<button id="usa-accordion__button_second-5 usa-nav__submenu-list-2" class="usa-accordion__button_second usa-nav__link is_expanded closed" aria-expanded="false" aria-controls="basic-nav-section-Measure-Implementation">
|
||
<span>CMS Consensus-Based Entity (CBE) Endorsement and Maintenance</span>
|
||
</button>
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-CMS-Consensus-Based-Entity-(CBE)-Endorsement-and-Maintenance" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-CMS-Consensus-Based-Entity-(CBE)-Endorsement-and-Maintenance" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-implementation/CMS-CBE-EM/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-implementation/CMS-CBE-EM/Measure-Submission-to-the-CMS-CBE">
|
||
<span>Measure Submission to the CMS CBE</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-implementation/CMS-CBE-EM/Endorsement-Process">
|
||
<span>The CMS CBE Endorsement Process</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</div>
|
||
|
||
|
||
<div class="desktop:grid-col-3">
|
||
|
||
<div class="usa-nav__headermenu-item">
|
||
<span><strong>Measure Use, Continuing Evaluation & Maintenance</strong></span>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Measure-Use,-Continuing-Evaluation-&-Maintenance" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Measure-Use,-Continuing-Evaluation-&-Maintenance" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-use/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-use/production-and-monitoring">
|
||
<span>Measure Production & Monitoring</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-use/evaluation">
|
||
<span>Continuing Evaluation</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_expanded">
|
||
|
||
|
||
|
||
<button id="usa-accordion__button_second-6 usa-nav__submenu-list-2" class="usa-accordion__button_second usa-nav__link is_expanded closed" aria-expanded="false" aria-controls="basic-nav-section-Measure-Use,-Continuing-Evaluation-&-Maintenance">
|
||
<span>Measure Maintenance Reviews</span>
|
||
</button>
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Measure-Maintenance-Reviews" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Measure-Maintenance-Reviews" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-use/maintenance/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-use/maintenance/annual-update">
|
||
<span>Annual Update</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-use/maintenance/comprehensive-reevaluation">
|
||
<span>Comprehensive Reevaluation</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-use/maintenance/early-maintenance-review">
|
||
<span>Early Maintenance Review</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-use/maintenance/harmonization-during-maintenance">
|
||
<span>Harmonization during Measure Maintenance</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</div>
|
||
|
||
|
||
<div class="desktop:grid-col-3">
|
||
|
||
<div class="usa-nav__headermenu-item">
|
||
<span><strong>Interested Party Engagement</strong></span>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Interested-Party-Engagement" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Interested-Party-Engagement" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/stakeholder-engagement/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/stakeholder-engagement/lifecycle">
|
||
<span>Interested Party Engagement in the Measure Lifecycle</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/stakeholder-engagement/roles">
|
||
<span>Roles in Engagement</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/stakeholder-engagement/types">
|
||
<span>Types of Interested Party Engagement</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</div>
|
||
|
||
|
||
</div>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__primary-item is_expanded">
|
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|
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<button id="usa-accordion__button" class="usa-accordion__button usa-nav__link is_expanded " aria-expanded="false" aria-controls="extended-mega-nav-section-3">
|
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<span>Tools & Resources</span>
|
||
</button>
|
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|
||
|
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|
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<div id="extended-mega-nav-section-3" class="usa-nav__submenu usa-megamenu" hidden="">
|
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|
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|
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<div class="grid-row grid-gap-3 gridused">
|
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|
||
|
||
<div class="desktop:grid-col-3">
|
||
|
||
<div class="usa-nav__headermenu-item">
|
||
<span><strong>MMS Tools & Resources</strong></span>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-MMS-Tools-&-Resources" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-MMS-Tools-&-Resources" >
|
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|
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|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/tools-and-resources/mms-supplemental-materials">
|
||
<span>Supplemental Materials</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/tools-and-resources/mms-templates">
|
||
<span>Templates for Measure Development</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/educational-resources">
|
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<span>Educational Resources</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/mms-tools">
|
||
<span>MMS Tools</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</div>
|
||
|
||
|
||
<div class="desktop:grid-col-3">
|
||
|
||
<div class="usa-nav__headermenu-item">
|
||
<span><strong>Additional Tools & Resources</strong></span>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Additional-Tools-&-Resources" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Additional-Tools-&-Resources" >
|
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|
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|
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|
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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/cms-tools">
|
||
<span>CMS Tools</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/external-resources">
|
||
<span>External Resources</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="https://mmshub.cms.gov/glossary">
|
||
<span>Glossary</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</div>
|
||
|
||
|
||
<div class="desktop:grid-col-3">
|
||
|
||
<div class="usa-nav__headermenu-item">
|
||
<span><strong>Pre-Rulemaking Resources</strong></span>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Pre-Rulemaking-Resources" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Pre-Rulemaking-Resources" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/Pre-Rulemaking-Resources">
|
||
<span>Pre-Rulemaking Resources</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</div>
|
||
|
||
|
||
</div>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__primary-item is_expanded">
|
||
|
||
<button id="usa-accordion__button" class="usa-accordion__button usa-nav__link is_expanded " aria-expanded="false" aria-controls="extended-mega-nav-section-4">
|
||
<span>Get Involved</span>
|
||
</button>
|
||
|
||
|
||
|
||
<div id="extended-mega-nav-section-4" class="usa-nav__submenu usa-megamenu" hidden="">
|
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|
||
|
||
<div class="grid-row grid-gap-3 gridused">
|
||
|
||
|
||
<div class="desktop:grid-col-3">
|
||
|
||
<div class="usa-nav__headermenu-item">
|
||
<span><strong>Get Involved</strong></span>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Get-Involved" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Get-Involved" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/get-involved/how-to">
|
||
<span>How to Get Involved</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_expanded">
|
||
|
||
|
||
|
||
<button id="usa-accordion__button_second-1 usa-nav__submenu-list-2" class="usa-accordion__button_second usa-nav__link is_expanded closed" aria-expanded="false" aria-controls="basic-nav-section-Get-Involved">
|
||
<span>Technical Expert Panels</span>
|
||
</button>
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Technical-Expert-Panels" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Technical-Expert-Panels" >
|
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|
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|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/get-involved/technical-expert-panel/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/get-involved/technical-expert-panel/current">
|
||
<span>Current TEP Opportunities</span>
|
||
</a>
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<div property="schema:text" class="field field--name-body field--type-text-with-summary field--label-hidden field__item"><p>A <abbr tabindex="0" title="<p>The <span class="glossify-exclude">denominator</span> is a statement describing the population evaluated by the performance measure and is the lower part of a fraction used to calculate a rate, proportion, or ratio. It can be the same as the target/initial population or a subset of the target/initial population to further constrain the population for the purpose of the measure. CV measures may refer to this as measure population.</p> " class="glossify-tooltip-tip" lang="en">denominator</abbr> exception allows the <abbr tabindex="0" title="<p><span class="glossify-exclude">Measured entities</span> are the front-line clinicians and their organizations, including health information technology, collecting quality measurement data. <span class="glossify-exclude">Measured entities</span> are the implementers of quality measures. The effect of quality measure data collection on clinician workflow can be negative. There may be effects on their payments, positive and negative, with respect to reporting and actual performance on quality measures. Because of these potential effects, <span class="glossify-exclude">measured entities</span> should be involved in all aspects of the Measure Lifecycle.</p> " class="glossify-tooltip-tip" lang="en">measured entity</abbr> to get credit when the measured entity performs the quality action, but not penalized if not done for an appropriate reason. The exception allows the exercise of clinical judgment and implies the measured entity considered or offered treatment to each potentially eligible patient in the denominator. Denominator exceptions are most appropriate when measures of contraindications to drugs or procedures are relative (<a href="https://doi.org/10.1161/CIR.0b013e3181f7d78c">Spertus et al., 2010</a>). A measure developer should specifically define a denominator exception when capturing the information in a structured manner fitting the clinical workflow. The measure developer should only use a denominator exception in <abbr tabindex="0" title="<p>A <span class="glossify-exclude">proportion</span> is a score derived by dividing the number of cases meeting a criterion for quality (i.e., the numerator) by the number of eligible cases within a given time frame (i.e., the denominator) where the numerator cases are a subset of the denominator cases (e.g., percentage of eligible women with a mammogram performed in the last year).</p> " class="glossify-tooltip-tip" lang="en">proportion</abbr> measures. It is not appropriate for <abbr tabindex="0" title="<p>A <span class="glossify-exclude">ratio</span> is a score derived by dividing a count of one type of data by a count of another type of data (e.g., number of patients with central lines who develop infection divided by the number of central line days). The key to the definition of a <span class="glossify-exclude">ratio</span> is that the numerator is not in the denominator.</p> " class="glossify-tooltip-tip" lang="en">ratio</abbr> or <abbr tabindex="0" title="<p>A <span class="glossify-exclude">continuous variable</span> is a measure score in which each individual value for the measure can fall anywhere along a continuous scale and can be aggregated using a variety of methods such as the calculation of a mean or median (e.g., mean number of minutes between presentation of chest pain to the time of administration of thrombolytics).</p> " class="glossify-tooltip-tip" lang="en">continuous variable</abbr> measures.</p><p>Although no single agreed-upon approach to denominator exceptions exists, there seems to be consensus that denominator exceptions provide valuable information for clinical decision-making. Measure developers who build denominator exceptions into measure <abbr tabindex="0" title="<p><span class="glossify-exclude">Logic</span> is the criteria used to define a quality measure and its key components.</p> " class="glossify-tooltip-tip" lang="en">logic</abbr> should be aware that—once implemented— denominator exception rates may be subject to reporting, auditing, endorsement/maintenance review, and <abbr tabindex="0" title="<p>Validation is testing to determine whether the measure accurately represents the evaluated concept and achieves the purpose for which the measure developer intended (i.e., to measure quality). Measure developers use validation in reference to statistical risk models where they compare model performance metrics between two different samples of data called the development and validation samples.</p> " class="glossify-tooltip-tip" lang="en">validation</abbr> of appropriateness. The measure developer should account for these factors in measure design and development. </p><table><thead><tr><th><p class="text-align-center"><strong>Reasons for Denominator Exceptions</strong></p></th><th><p class="text-align-center"><strong>Description</strong></p></th><th><p class="text-align-center"><strong>Examples</strong></p></th></tr></thead><tbody><tr><th><p class="text-align-center"><strong>Medical Reasons</strong></p></th><td>Medical reasons should be precisely defined and evidence-based. The events excepted should occur often enough to distort measure results if not accounted for. A broadly defined medical reason such as “any reason documented by physician” may create an uneven comparison if some physicians have reasons that may not be evidence-based. </td><td><p>Medication specified in the <abbr tabindex="0" title="<p>The <span class="glossify-exclude">numerator</span> is the upper portion of a fraction used to calculate a rate, proportion, or ratio. Also called the measure focus, it is the target process, condition, event, or outcome. <span class="glossify-exclude">Numerator</span> criteria are the processes or outcomes expected for each patient, procedure, or other unit of measurement defined in the denominator. A <span class="glossify-exclude">numerator</span> statement describes the action satisfying the conditions of the performance measure.</p> " class="glossify-tooltip-tip" lang="en">numerator</abbr> is known to cause harm to fetuses, and there is documentation the patient’s pregnancy is the reason for not prescribing an indicated medication. If in the course of a measure’s use, the measure developer finds that medical reasons resulting in a denominator exception occur in a high enough volume and are of universal applicability, then the measure developer can consider the denominator exception for redefinition as a denominator exclusion. </p><p>Asthma is an allowable denominator exception for the <abbr tabindex="0" title="<p>The Patient Protection and Affordable Care Act defined a <span class="glossify-exclude">quality measure</span> as “a standard for measuring the performance and improvement of population health or of health plans, providers of services, and other clinicians in the delivery of health care services.” (<a href="https://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf">Pub. L. 111-148, 931</a>)</p> " class="glossify-tooltip-tip" lang="en">quality measure</abbr> of the use of beta blockers for patients with heart failure. Thus, physician judgment may determine there is greater benefit for the patient to receive beta blockers for heart failure than the risk of a problem occurring due to the patient’s coexisting condition of asthma. If the measured entity gives the medication, the measure implementer does not search for denominator exceptions, and the patient remains in the denominator. If the measured entity did not give the medication, the implementer looks for relevant denominator exceptions and removes the patient−in this example, a patient with asthma−from the denominator. If the measured entity did not give the medication and the patient does not have any denominator exceptions, the patient remains in the denominator and the measured entity fails the measure.</p></td></tr><tr><th><p class="text-align-center"><strong>Patient Reasons</strong></p></th><td>Patient reasons for not receiving the service specified may be a denominator exception to allow for patient preferences. </td><td>The patient has a religious conviction precluding the patient from receiving the specific treatment, the physician explained the benefits of the treatment, and documented the patient’s refusal in the record.</td></tr><tr><th><p class="text-align-center"><strong>System Reasons</strong></p></th><td>System reasons are generally rare. The measure developer should limit these to identifiable situations that are known to occur.</td><td>A vaccine shortage prevented administration of the vaccine.</td></tr></tbody></table><p>The measure developer must capture the denominator exception with explicitly defined <abbr tabindex="0" title="<p>A data element is a basic unit of information with a unique meaning and subcategories (data items) of distinct value. National Institute of Standards and Technology. (n.d.). <em>Data element</em>. Computer Security Resource Center. Retrieved November 1, 2023, from&nbsp;<a href="https://csrc.nist.gov/glossary/term/data_element">https://csrc.nist.gov/glossary/term/data_element</a></p> " class="glossify-tooltip-tip" lang="en">data elements</abbr> that allow analysis of the denominator exception across measured entities to identify patterns of inappropriate denominator exception and <abbr tabindex="0" title="<p><span class="glossify-exclude">Gaming</span> is when measured entities exploit weaknesses in the measurement system to tweak the data making their performance look better than it actually is. Includes limiting access to certain populations, neglecting care, or overuse of medications or services to ensure that the measure results are favorable.</p> " class="glossify-tooltip-tip" lang="en">gaming</abbr> and to detect potential <abbr tabindex="0" title="<p>Health care disparities generally refer to differences between groups in access to, use of, quality of care, or health coverage. CMS. 2021. P<em>aving the way to equity: A progress report 2015-2021</em>. Retrieved November 1, 2023, from&nbsp;<a href="https://www.cms.gov/files/document/paving-way-equity-cms-omh-progress-report.pdf">https://www.cms.gov/files/document/paving-way-equity-cms-omh-progress-report.pdf</a></p> " class="glossify-tooltip-tip" lang="en">health care disparity</abbr> issues. Analysis of rates without attention to denominator exception information has the potential to mask disparities in health care and differences in measured entity performance.</p><p><strong>Transparency and Evidence</strong></p><p>To ensure transparency, the measure developer should capture an allowable denominator exception in a way the measured entity can report it separately, in addition to the overall measure rate. The measure developer should support an allowable denominator exception with evidence</p><ul><li>Of sufficient frequency of occurrence such that distortion of the measure results occurs without the denominator exception</li><li>The denominator exception is clinically appropriate to the eligible <abbr tabindex="0" title="<p>The <span class="glossify-exclude">population</span> is the total group of people of interest for a quality measure, sometimes called the target/initial <span class="glossify-exclude">population</span>. The measure <span class="glossify-exclude">population</span> is a defined subset appropriate to the measure set not excluded from the individual measure.</p> " class="glossify-tooltip-tip" lang="en">population</abbr> for the measure</li></ul><p>Although no single agreed-upon approach to denominator exceptions exists, there seems to be consensus that denominator exceptions provide valuable information for clinical decision-making. Measure developers who build denominator exceptions into measure logic should take caution that, once implemented, denominator exception rates may be subject to reporting, auditing, endorsement/maintenance review, and validation of appropriateness. The measure developer should account for these factors in measure design and development.</p><dl class="ckeditor-accordion"><dt>Examples</dt><dd><ul><li>Inappropriate denominator exception: a notation in the patient’s <abbr tabindex="0" title="<p>The medical record is data obtained from the records or documentation maintained on a patient in any health care setting (e.g., hospital, home care, long term care, practitioner office). Includes electronic and paper medical record systems.</p> " class="glossify-tooltip-tip" lang="en">medical record</abbr> indicates a reason for not performing the specified care, and scientific evidence does not support the reason.</li><li>Gaming: patient refusal may be a denominator exception; however, it has the potential for overuse. For example, a measured entity does not actively encourage the service, explain its advantages, or attempt to persuade the patient, and then uses patient refusal as the reason for nonperformance.</li><li>Disparity issues: the use of a patient reason for denominator exception for mammograms is found to be high for a minority population, which may indicate a need for more targeted, culturally appropriate patient education or closer examination of patient access issues such as lack of transportation or lack of childcare.</li></ul></dd></dl></div>
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